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THE 



PRINCIPAL DISEASES 



INTERIOR YALLEY OF NORTH AMERICA. 



SYSTEMATIC TREATISE, 

HISTORICAL, ETIOLOGICAL, AND PRACTICAL, 

ON THE 

PKINCIPAL DISEASES 

OF THE 

INTERIOR VALLEY OF NORTH AMERICA, 



AS THEY APPEAR IN THE 



CAUCASIAN, AFRICAN, INDIAN, AND ESQUIMAUX 
VARIETIES OF ITS POPULATION. 



BY 



DANIEL DRAKE, M.D. 



EDITED BY 

s/hANBURY SMITH, M.D., 

FORMERLY PROFESSOR OF THEORY AXD PRACTICE OF MEDICINE IN 
STARLING MEDICAL COLLEGE, OHIO, 



FRANCIS G. SMITH, M.D., 

PROFESSOR OF THE INSTITUTES OF MEDICINE IN THE MEDICAL DEPARTMENT 
OF PENNSYLVANIA COLLEGE, PHILADELPHIA. 




PHILADELPHIA: 

LIPPINCOTT, GRAMBO & CO., PUBLISHERS. 

1854. 




-5> 



y 



Entered, according to Act of Congress, in the year 1854, 

BY LIFPINCOTT, GBAMBO AND CO., 

In the Clerk's Office of the District Court for the Eastern District of Pennsylvania. 



EDITORS' NOTICE. 



Some time after the death of the lamented author of the follow- 
ing pages, his manuscripts were placed in our hands to prepare for 
the press. In performing this duty we discovered that although he 
had bestowed a vast amount of care on the matter and its arrange- 
ment, evident in the numberless additions at different periods to the 
former, and alterations of the latter, as well as in the entire remo- 
delling of many chapters, yet but little had been left in a condition 
to place in the printer's hands. In the work of correction and com- 
pletion, we have endeavored to present the author as nearly as pos- 
sible in the dress and manner he would have chosen himself. The 
great labor involved in thus editing upwards of three thousand pages 
of manuscript can scarcely be realized except by those having expe- 
rience in such matters. By far the larger portion of this labor was 
performed in the intervals begrudgingly afforded by extensive prac- 
tice, and with an importunate sense of the expediency of publication 
on the earliest possible day, — circumstances not favorable to the com- 
pletion of the undertaking in the manner we should have desired. 

September, 1854. 



TABLE OF CONTENTS, 



BOOK SECOND. 
PART I. 

AUTUMNAL FEVER. 
CHAPTER I. 



FEVER, TOGETHER WITH THE TOPOGRAPHICAL AND CLIMATIC CONDI- 
TIONS UNDER WHICH IT PREVAILS. 

PAGE 

Sect. I. Nomenclature. — Variety. — Identity, .... 17 

II. Geographical Limits, ...... 18 

III. Conditions which impose Geographical Limits, and give unequal 

prevalence to Autumnal Fever, .... 23 

CHAPTER II. 

SPECULATIONS ON THE EFFICIENT CAUSE OF AUTUMNAL FEVER. 

Sect. I. Meteoric Hypothesis, . . . . -. .30 

II. Malarial Hypothesis, . . . ... . 33 

III. Vegeto-Animalcular Hypothesis, . . . .37 

CHAPTER III. 

MODE OF ACTION, AND FIRST EFFECTS OF THE REMOTE CAUSE OF 
AUTUMNAL FEVER. 

Sect. I. Application of the Poison,, ..... 43 

II. Mode of Action, ....... 46 



Vlll TABLE OF CONTENTS. 



CHAPTER IV. 

VARIETIES AND DEVELOPMENT OF AUTUMNAL FEVER. 

Sect. I. Varieties, ....... 48 

II. Development and Pathological Character, . .51 



CHAPTER V. 

INTERMITTENT FEVER. — SIMPLE AND INFLAMMATORY. 

Sect. I. Simple Intermittents — History and Pathology, . . 56 

II. Treatment of Simple Intermittents, . . . .57 

III. Inflammatory Intermittents, ..... 66 



CHAPTER VI. 

MALIGNANT INTERMITTENT FEVER. 

Sect. I. General History, . . . . . .71 

II. Symptomatology, ...... 73 

III. Pathology and Complications, . . . . .80 

IV. Treatment in the Paroxysm, . . . . . 81 
V. Treatment in the Intermission, . . . . .89 

VI. Conclusion, ....... 94 

CHAPTER VII. 

REMITTENT AUTUMNAL FEVER — SIMPLE AND INFLAMMATORY — 

CONSIDERED TOGETHER. 

Sect. I. Symptoms, . . . . . . .95 

II. Treatment, . . . . . . 98 

CHAPTER VIII. 

MALIGNANT REMITTENT FEVER. 

Sect. I. General Remarks, . . . . . . .111 

II. Diagnosis and Pathology, . . . . . 112 

III. Treatment, . 116 

CHAPTER IX. 

PROTRACTED, RELAPSING, AND VERNAL INTERMITTENTS. 

Sect. I. Chronic and Relapsing Cases, .... 127 

II. Vernal Intermittents, . . . . . .129 

III. Treatment — Hygienic and Medical, . . . . 131 



TABLE OF CONTENTS. IX 



CHAPTER X. 

PATHOLOGICAL ANATOMY AND CONSEQUENCES OF AUTUMNAL FEVER. 

Sect. I. Mortality of Autumnal Fever, . . . . .136 

II. Condition of the Blood in Autumnal Fever, . . . 137 

III. Pathological Anatomy of Intermittent Fever, . . .138 

IV. Pathological Anatomy of Remittent Fever, . . . 142 
V. Consequences of Autumnal Fever, . ... .150 





CHAPTER XL 






CONSEQUENCES OF AUTUMNAL FEVER. 




Sect. I. 


Diseases of the Spleen: General Views, 


153 


II. 


Splenitis, ....... 


. 157 


III. 


Suppuration of the Spleen, .... 


159 


IV. 


Enlargement of the Spleen, .... 


. 161 


V. 


Diseases of the Liver, .... 


168 


VI. 


Dropsy, ....... 


. 174 


VII. 


Periodical Neuralgia, .... 


182 



PART II. 

YELLOW FEVER. 

CHAPTER I. 

Sect. I. Nomenclature — Definition — Sources of information, . . 187 

II. Geography and Chronology, ..... 188 

III. Local History, . . . . . . .191 

CHAPTER II. 

LOCAL HISTORY. — NEW ORLEANS. 

Sect. I. Condition of the city. — Prevalence in, 192 

II. Time of commencement. — Prevalence in different years and 

months, compared with Autumnal Fever, . . . 196 

III. Annals of the Fever at New Orleans, . . . 201 



X TABLE OF CONTENTS, 

CHAPTER III. 

LOCAL HISTORY. — PLACES EAST AND SOUTHEAST OF THE DELTA OF THE 

MISSISSIPPI. 

Sect. I. TheBalize, . . . . . . .211 

II. Military posts, . . . . . . 213 

III. Civil stations between New Orleans and Mobile. . .213 

IV. Bay and City of Mobile, . . . . . 216 
V. Pensacola Bay, . . . . . . .225 

VI. St. Joseph's, Apalachicola Bay, and Tampa Bay, . . 235 

VII. Key West, or Thompson's Island, . . . .235 

CHAPTER IY. 

LOCAL HISTORY. — PLACES TO THE WESTWARD AND NORTHWEST OF 

NEW ORLEANS, . . . 236 

CHAPTER V. 

PLACES UP THE MISSISSIPPI FROM NEW ORLEANS, . 246 

CHAPTER YI. 

ETIOLOGICAL DEDUCTIONS FROM THE FACTS PRESENTED IN THE 

FOREGOING HISTORIES, . . . 286 

CHAPTER VII. 
Symptoms, ......... 299 

CHAPTER VIII. 

Pathological Anatomy, ....... 303 

Sect. I. Special Lesions, ....... 304 

II. Generalizations, . . . . . . 314 

III. Lesions of the Blood, . . . . . .316 

CHAPTER IX. 

Pathology, . . . . . . . . 319 

CHAPTER X. 

TREATMENT. 
Sect. I. Self-limitation —Prevention. . . . . .321 



TABLE OF CONTENTS. XI 

Sect. II. Remedies for the first and second stages, . . . 322 
III. Remedies in the third stage, ..... 343 

CHAPTER XL 

MISCELLANEOUS OBSERVATIONS. 

Sect. I. Mortality, . . . . . . . 351 

II. Comparison of Yellow Fever with Autumnal Fever, . .353 



PART III. 

TYPHOUS FEVERS. 
CHAPTER I. 

INTRODUCTION. — GENERAL EPIDEMIC. — TYPHOUS CONSTITUTION. 

Sect. I. Introduction, ....... 358 

II. A general Typhous Epidemic Constitution, . . . 361 

CHAPTER II. 

LOCAL HISTORIES OF OUR CONTINUED OR TYPHOUS FEVERS. — SOUTHERN 
BASIN, APALACHIAN MOUNTAIN REGION. 

Sect. I. Sub-epidemic and Sporadic Visitations, . . . 368 

II. Sub-epidemic at Elliottsville, New York. . . .369 

III. Sub-epidemic at Parisburg, Virginia, . . . 370 

IV. Sub-epidemics in Buncombe County, North Carolina, . . 373 
V. In the Sub-Alpine parts of East Tennessee. . . . 377 

CHAPTER III. 

LOCAL HISTORIES OF TYPHOUS FEVERS IN THE SOUTHERN BASIN, CON- 
TINUED J IN PENNSYLVANIA, OHIO, INDIANA, AND ILLINOIS. 

Sect. I. In and around Uniontown, Pennsylvania, . . . 378 

II. In Washington and the surrounding country, . . 380 

III. In and around Pittsburg, . . . . . .382 

IV. In Trumbull and adjoining counties. . . . 383 

V. In Belmont and adjoining counties, .... 385 
VI. In Greene County, Ohio, ..... 390 

VII. In and around Lane Theological Seminary, . . . 392 

VIII. Indiana and Illinois, ...... 399 



Xll TABLE OF CONTENTS. 



CHAPTER IV. 



LOCAL HISTORIES OF TYPHOUS FEVERS; SOUTHERN BASIN, KENTUCKY. 

Sect. I. In Bourbon County, ...... 400 

II. In Scott County, ...... 402 

III. In Oldham County, . . . . . .407 



CHAPTER V. 

LOCAL HISTORIES OF THE TYPHOUS FEVERS OF THE SOUTHERN BASIN 
CONTINUED. — IN TENNESSEE. 

Sect. I. In Smith County, . . . . . . 410 

CHAPTER VI. 

LOCAL HISTORY OF TYPHOUS FEVERS OF THE SOUTHERN BASIN IN 
ALABAMA AND MISSISSIPPI. 

Sect. I. In North Alabama, . . . . . .412 

II. In Maury County, . . . . . . 413 

III. In Benton County, South Alabama, . . . .415 

IV. Further South. — In and around Dallas County, . . 418 
V. In Mississippi, Carroll County, ..... 420 

VI. Epidemic Typhous Fever in New Mexico, . . . 421 

CHAPTER VII. 

CONTINUED OR TYPHOUS FEVERS OF THE EASTERN OR ST. LAWRENCE 

BASIN. 

Sect. I. Within the United States, . . . . . • .422 

II. In the Canadas, ...... 426 

CHAPTER VIII. 

IRISH EMIGRANT FEVER, . . 430 

CHAPTER IX. 

ETIOLOGICAL GENERALIZATIONS. 

Introduction, ......... 441 

Sect. I. Climatic Relations, ...... 442 

II. Topographical Relations, ...... 447 

III. Physiological and Domestic Influences, . . . 449 



TABLE OF CONTENTS. Xlll 

CHAPTER X. 

etiological generalizations continued j sporadic and epidemic 
prevalence; contagious propagation. 

Sect. I. Sporadic Typhous, Primary and Secondary, . . . 452 

II. Contagious Propagation, ..... 454 

III. Local or Spontaneous Origin of Epidemic Typhous, . . 457 

IV. Connection between Contagion aud Local Origin, . . - 462 

CHAPTER XL 

CLASSIFICATION OF CONTINUED FEVERS, . . 464 



CHAPTER XII. 

SYMPTOMS OF CONTINUED OR TYPHOUS FEVERS, . 471 

Sect. I. Of the Forming Stage, . . . . . .472 

II. Stage of Excitement, ...... 474 

III. Progress and Termination of the Fever, .... 483 



CHAPTER XIII. 

PATHOLOGICAL ANATOMY OF TYPHOUS FEVERS, . 486 

CHAPTER XIV. 

PATHOLOGY OF TYPHOUS FEVER, . . 493 

CHAPTER XV. 

TREATMENT OF TYPHOUS FEVERS. 

Sect. I. Difficulties, Uncertainties, and Failures, . . . 508 

II. Treatment in the Forming Stage, . .... 511 

III. Treatment of the earlier periods of the Stage of Excitement, 514 

IV. Treatment of the early part of the Stage of Excitement, . .516 
V. Treatment of the more advanced and final stages of the Typhous 

Fevers, ....... 534 

VI. Treatment in the Final Stages, . . . . 543 

VII. Care of the Patient and his Chamber in the Final Stage, . 550 



TABLE OF CONTENTS. 



CHAPTER XVI. 



RELATIONS OF TYPHOUS FEVERS WITH YELLOW, REMITTENT, AND OTHER 
FEBRILE DISEASES; SECONDARY TYPHOUS; TYPHOID STAGE. 

Sect. I. Yellow and Typhous Fever; Ictero-Typhous, . . . 554 

II. Remittent, Autumnal, and Typhous Fevers, . . . 556 

III. Treatment of Secondary, or Remitto-Typhous Fevers, . . 559 

IV. Typhous complication with various other diseases, . . 560 



PART IV. 

ERUPTIVE FEVERS. 
Introduction, . . . . . . . . 563 

CHAPTER I. 

SMALL-POX [VARIOLA]. 

Sect. I. Prevalence and Etiology, ...... 565 

II. Symptoms, ....... 566 

III. Pathological Anatomy, . . . . . 569 

IV. Treatment, . . . . . . . 570 



CHAPTER II. 

COW-POX. — VACCINIA. — VARIOLA VACCINIA. 

Sect. I. History and value as a Prophylactic of Small-Pox, . . 572 

II. Management, . . . . . . . 575 



CHAPTER III. 

MODIFIED SMALL-POX, VARIOLOID. — RELATIONS TO VARIOLA 

AND VACCINIA, . . . .579 

CHAPTER IV. 

VARICELLA OR CHICKEN-POX, . . 584 

CHAPTER V. 

MEASLES. — RUBEOLA, . . .586 



TABLE OF CONTENTS. XV 

CHAPTER VI. 

SCARLET FEVER. — SCARLATINA. 

Sect. I. Historical notices, ...... 594 

II. Scarlatina and Measles combined, .... 608 

CHAPTER VII. 

ROSE RASH. — ROSEOLA: ALSO, LICHEN AND STROPHULUS, 612 

CHAPTER VIII. 

NETTLE RASH. — URTICARIA, . . .614 

CHAPTER IX. 

ERYSIPELAS. — INTRODUCTORY. 

Sect. I. Sporadic Erysipelas, . . . . . 619 

II. Epidemic Erysipelas. — Chronology, geography, and contagion, . 622 

III. Epidemic Erysipelas continued : Symptoms, . . 630 

IV. Epidemic Erysipelas, continued: Pathology, . . . 636 
V. Epidemic Erysipelas, continued : Treatment, . . 638 



PART V. 

PHLOGISTIC FEVERS: THE PHLEGMASIA. 
CHAPTER I. 

COMPARISON WITH THE PREVIOUS GROUPS. — CLASSIFICATION. 

Sect. I. Comparisons and contrasts. ..... 647 

II. Classification, . . . . . . . 651 

CHAPTER II. 

ETIOLOGY OF THE PHLOGISTIC FEVERS. — PREDISPOSING AND MODIFYING 
CAUSES. — INTRODUCTION. 

Sect. I. Temperament, individual and' national. — Age. — Sex, . . 653 

II. Climate. ....... 656 



XVI TABLE OF CONTENTS. 

Sect. III. Diets, drinks, and dress, ..... 658 

IV. Occupations, casualties, mental cultivation. — Passions, . 661 

V. Pathological and modifying causes, .... 664 
VI. Causes which produce specific phlegmasia?, . . 657 

CHAPTER III. 

RISE AND ESTABLISHMENT OF THE SIMPLE OR COMMON PHLEGMASIA, 
AND STATE OF THE BLOOD IN THEM. 

Sect. I. Of their rise and establishment, . . . . 669 

II. Condition of the Blood in phlegmasia?, . . . 673 

III. Speculations on the production of Hyperinosis, . . . 679 

CHAPTER IV. 



PHLEGMASIA. 

Sect. I. Progress and Terminations, . . . . . 684 

II. Anatomical Lesions, ...... 686 



CHAPTER V. 

INDICATIONS AND MEANS OF CURE, . . 688 

CHAPTER VI. 

PHLEGMASIA OF THE CENTRAL ORGANS OF INNERVATION, BRAIN, AND 
SPINAL CORD, WITH THEIR MEMBRANES. 

Sect. I. Anatomico-Physiological Introduction, .... 702 
II. Congestion of the Brain, ..... 703 

CHAPTER VII. N 

PHLEGMASIA OF THE CENTRAL ORGANS OF INNERVATION, BRAIN, AND 
SPINAL CORD, WITH THEIR MEMBRANES. 

Sect. I. Prevalence and Causes, . . . . . .713 

II. Classification and Diagnosis, . . . . . 715 

III. Pathology and Pathological Lesions, .... 722 

IV. Prevention and cure of Cerebro-meningitis, . . 725 

CHAPTER VIII. 

INFLAMMATION OF THE NERVOUS CENTRES CONTINUED I TUBERCULAR 
ENCEPHALITIS. — HYDROCEPHALUS. . .735 



TABLE OP CONTENTS. 



CHAPTER IX. 

INFLAMMATIONS OF THE NERVOUS CENTRES.— BRAIN AND SPINAL MAR- 
ROW CONTINUED. MYELITIS AND CEREBRO-MYELITIS. 

Sect. I. Sporadic Myelitis. — Parenchymal and meningeal, . . 745 

II. Epidemic cerebro-spinal meningitis, .... 751 

CHAPTER X. 

INFLAMMATIONS OF THE ORGANS OF MOTION, AND OF SPECIAL SENSE. 
RHEUMATISM. — OPHTHALMIA. 

Sect. I. Rheumatism, ....... 764 

II. Ophthalmia, . . . . . . ■ . 782 

CHAPTER XL 

PHLEGMASIA OF THE RESPIRATORY ORGANS. — ETIOLOGY. 

Introduction, ........ 787 

Sect. I. Climatic, geographical, and hydrographical causes, . . 787 

II. Miscellaneous causes of Pulmonary Inflammation, . 799 

CHAPTER XII. 

MUCOUS INFLAMMATIONS OF THE RESPIRATORY ORGANS. — CATARRH. — 



Sect. I. Endemic Catarrh, ...... 807 

II. Influenza, or Exotic Epidemic Catarrh, . . . 809 

III. Acute Laryngitis, . . . . . . .810 

IV. Chronic Laryngitis. — Diseases of public speakers. — Clergyman's 

sore throat, . . . . . . 815 

V. Laryngo-Trachitis, Cynanche Trachealis, or Croup, . .819 



CHAPTER XIII. 

LARYNGISMUS STRIDULUS. — PERTUSSIS. ASTHMA. — HAY-ASTHMA. 

Sect. I. Laryngismus Stridulus, Spasmodic Croup, or Child-Crowing, . 826 

II. Pertussis, or Hooping-Cough, . ... . 828 

III. Asthma, ........ 833 

IV. Hay Asthma. — Summer Catarrh, Catarrhus iEstivus, . 838 



XV111 TABLE OF CONTENTS. 



CHAPTER XIV. 

ACUTE AND CHRONIC BRONCHITIS. — BRONCHIAL CONSUMPTION. 

Sect. I. Acute Bronchitis, . . . . . . 840 

II. Sub-acute or Chronic Bronchitis, .... 844 

III. Bronchial Consumption, ...... 846 



CHAPTER XV. 

PNEUMONIA AND PLEURISY. 

Sect. I. Geography, Chronology, and Subjects, . . . 852 

II. Diagnosis and Lesions of Pneumonia, .... 854 

III. Treatment of Pneumonia, ..... 860 



CHAPTER XVI. 

TYPHOID AND BILIOUS PNEUMONITIS. 

Sect. I. Typhoid Pneumonitis, ... . . . . 866 

II. Bilious Pneumonitis, ...... 868 

CHAPTER XVII. 

PLEURISY, ACUTE AND CHRONIC. — PLEURITIC CONSUMPTION. 

Sect. I. Acute Pleurisy, ....... 874 

II. Chronic Pleurisy, . . . . . . 876 

III. Pleuritic Consumption, ...... 879 



CHAPTER XVIII. 

TUBERCULAR PNEUMONITIS OR PHTHISIS PULMONALIS — ETIOLOGY AND 

PROPHYLAXIS. 

Introduction, ........ 883 

Sect. I. Relations between Climate and the Consumptive or Tubercular 

Diathesis, ....... 884 

II. Miscellaneous external causes which originate or promote a 

Tubercular Diathesis. ..... 902 

III. Pathological causes of a Tubercular Diathesis. — Infirmities of 

Parents. — Contagion. — Hereditary Transmission, . .910 



TABLE OF CONTENT^. XIX 

CHAPTER XIX. 

TUBERCULAR PNEUMONITIS CONTINUED : DIAGNOSIS OF THE EARLY 
STAGES^ PATHOLOGY AND TREATMENT. 

Sect. I. Early distinctive symptoms and signs of Phthisis, . .921 

II. Pathology and progress of Phthisis, .... 929 

III. Treatment of Phthisis, . . ... . .937 

CHAPTER XX. 

CARDIAC INFLAMMATIONS. 

Sect. I. Introduction, ....... 945 

II. Classification and general symptoms of Cardiac Inflammations, 946 

III. Peculiar symptoms and pathological characters of Pericarditis, . 951 

IV. Endocarditis: symptoms and pathological characters, . 953 
V. Symptoms and effects of Carditis, .... 955 

VI. Causes of Cardiac Inflammation, .... 958 

VII. Sequelee of Cardiac Inflammation, .... 964 

VIII. Cure of Cardiac Inflammation, .... 965 



THE 

PRINCIPAL DISEASES 

OF THE 

INTERIOR VALLEY OF NORTH AMERICA. 



5600k Sbttittib. 

FEBRILE DISEASES 



PART FIRST. 

AUTUMNAL FEVER. 



CHAPTER I. 

NOMENCLATURE, VARIETIES, AND GEOGRAPHICAL LIMITS OF AUTUMNAL 

FEVER, TOGETHER WITH THE TOPOGRAPHICAL AND CLIMATIC 

CONDITIONS UNDER WHICH IT PREVAILS. 



SECTION I. 

NOMENCLATURE. — VARIETY. — IDENTITY. 

I. Nomenclature. — In different parts of the Interior Valley, the fevers, 
which we are about to study, are known under the names — autumnal, 
bilious, intermittent, remittent, congestive, miasmatic, malarial, marsh, ma- 
lignant, chill-fever, ague, fever and ague, dumb ague, and lastly, the Fever. 
So great a variety of names suggests two facts : first, diversity of type ; 
second, wide geographical range of prevalence. I shall use the epithet 
autumnal, as involving no etiological or pathological hypothesis; and at the 
same time, including every modification; but, in speaking of diversities, 
other terms will find their appropriate places. 

II. Variety and Identity. — The varieties of autumnal fever are nu- 
merous, and often seem widely separated. Thus, the difference in pheno- 
mena between a simple tertian and an inflammatory or a malignant remittent, 
is greater than the difference between measles and scarlatina ; in some years 
nearly all the cases that occur are intermittent, in others remittent ; finally, 

vol. 11. 2 



18 THE PRINCIPAL DISEASES OP THE 

although the former seem to be but mild grades of the latter, they often 
prove suddenly fatal ; and, that too, without assuming a remittent type. 
Nevertheless, all the varieties must be regarded as making but a single 
species ; as appears from the following facts : First. They prevail at the 
same times and in the same places. Second. Under much variety of 
aspect, they possess many deep-seated analogies and identities. Third. They 
frequently change from one type to the other. Thus an intermittent turns 
into a remittent, and the latter, assuming the type of the former, is often 
seen to become, first, a quotidian, then a tertian, and finally, a quartan. A 
simple intermittent may, in the third or fourth paroxysm, take on the cha- 
racter of a fatal congestive ; and that which begins with an aspect of malig- 
nity, sometimes emerges into simplicity and mildness. Fourth. Vernal 
agues attack those who in autumn had suffered under remittent fever, not 
less than those who had experienced the intermittent form. Fifth. The 
sequelae of all the varieties are almost identical. Sixth. The same treat- 
ment with certain modifications, is applicable to the whole. Thus they are 
manifestly the offspring of the same specific, remote cause ; and when no 
particular variety is in view, may be designated by one epithet. 



SECTION II. 



GEOGRAPHICAL LIMITS. 



Being an endemic of all hot climates we need not look to the shores of 
the G-ulf of Mexico for a southern limit to our autumnal fever. Its base is, 
in fact, within the tropics ; and prevailing, of course, in Havana and Vera 
Cruz, it is found wherever there are inhabitants, on the northern coasts of 
the Gulf, between those two cities. In ascending all the rivers which dis- 
charge their waters into the northern arc of that closed sea, from Cape 
Florida round to the Panuco River, it is still met with ; and, sometimes, as 
we shall hereafter see, from the influence of local causes, displays greater 
prevalence and malignity, than it shows further south and on a lower level. 

In every other direction than the south, this endemic has its geographical 
limits. To the east, its barrier is the Appalachian Mountains, into the very 
gorges of which, however, it ascends by the valleys which penetrate their 
flanks. But as that chain is not found south of the thirty-third degree of 
latitude, it has, below that parallel, no eastern limit but the Atlantic Ocean. 
To the southwest the Cordilleras of Mexico, and the southern Rocky 
Mountains, constitute its boundaries ; while, in higher latitudes, it ceases on 
the great plains of our western desert, long before we reach those 
Mountains. From what can be collected out of the travels and expeditions 



INTERIOR VALLEY OF NORTH AMERICA. 19 

of Lewis and Clark, Pike, Long, Catlin, Fremont, and Gregg, not less than 
from fur traders and Santa Fe merchants, it is almost unknown at the dis- 
tance of three hundred miles from the western boundary of the states of 
Missouri and Iowa, and above the latitude of 37° N. To the north it does 
not prevail as an epidemic beyond the forty-fourth parallel, and ceases to 
occur even sporadically about the forty-seventh. 

The observations from which these limits are deduced have been made on 
the resident inhabitants included within them ; on travellers into portions of 
country as yet unsettled; and on the soldiery of the American and British 
posts. From these army returns I have, with all possible care, constructed 
two tables, which may properly be introduced at this place. The American 
returns* purport to be for ten years; but this is true of a few only; and 
many of the others vary from each other in the number of years through 
which they run, whereby the conclusions deducible from them, are entitled to 
less confidence than if an equal number of observations, in the same years, 
had been made at each post. As the number of troops was never the same 
at two different posts, nor during two years the same, one thousand has in the 
returns been assumed as the mean strength of the whole; and the number 
of attacks of Fever, and the actual mean strength, have both been brought 
to that standard. The results offered in the table, then, are not what any 
post did afford, but what any or all would have given, had the actual strength 
been at all times one thousand men. At several of them, it will be perceived 
the number of attacks exceed the number of men, implying that some indivi- 
duals experienced several, in the course of the year. The returns are quar- 
terly, but the quarters are those of the calendar year, and therefore, do not 
exactly correspond with the seasons. 

The observing reader will perceive, that this table affords a variety of 
information : such as the decrease of the Fever in the north — its relative 
prevalence at different posts in the same latitude — the proportionate number 
of intermittent and remittent cases, and the comparative prevalence of both, 
in different seasons. 



* Forry's Statistical Report of the Sickness and Mortality of the Army of the United States; pre- 
pared under the direction of Thomas Lawson, M. D., Surgeon-General, Washington, 1S40. 



20 



THE PRINCIPAL DISEASES OF THE 



TABLE 

Showing the number of attacks of Autumnal Fever, in the different quar- 
ters OF THE YEAR, AT TWENTY-SIX MILITARY POSTS, BETWEEN THE GULF OF 

Mexico and Lake Superior — the mean strength being 1000. Arranged 
according to their latitudes. 



Twenty-six Posts. 


Autumnal Fever 


Quarters of the Year. 


Total 
of the 
Year. 


Comp. of 

annual 

aggregates. 


First. Second. 


Third. , Fourth 


Key West, N. Lat. 
24° 33', 


Intermittent, 
Remittent, 


70 
11 


52 
00 


6 ! 51 

! 00 


179 
11 




Both, 


81 


52 


6 


51 

182 

24 


190 


190 


Fort Brooke, N. 
Lat. 27° 57', 


Intermittent, 
Remittent, 


80 
13 


190 
24 


308 
28 


760 
89 




Both, 


yy i 214 


336 | 206 


849 


849 


Fort King, N. Lat, 
29° 12', 


Intermittent, 

Remittent, 

Both, 


120 
6 


200 
41 


460 
90 


414 

56 


1194 
193 




126 041 


550 | 470 


1387 


1387 


Fort Jackson, N. 
Lat. 29° 29', 


Intermittent, 
Remittent, 


8* ! 148 
4 ; 9 


816 
128 


367 
46 


1413 

187 




Both, 


«« | 157 


944 


413 


1600 


1600 


New Orleans Bar- 
racks, N. Lat. 
29° 57', 


Intermittent, 

Remittent, 

Both~ 

Intermittent, 

Remittent, 

Both, 


100 
10 


60 

60 

120 


50 
80 


84 
100 


294 
250 




110 


130 


184 


544 


544 


Fort Wood, N. Lat. 
30° 5', 

Fort Pike, N. Lat. 
30° 10', 


170 
3 


137 

55 

"192~~ 


339 

218 


125 

16 


771 

292 




173 


557 


140 


1063 ! 1063 


Intermittent, 
Remittent, 


28 
4 


56 
23 


40 
28 


31 
22 


155 

77 




Both, 


32 


79 


68 


53 
107 
100 

207 


232 232 


Baton Rouge, N. 
Lat. 30° 36', 


Intermittent, 
Remittent, 


71 
40 


124 
62 


220 
100 


522 
302 




Both, 


111 


186 


320 


824 | 824 


Fort Jesup, N.Lat. 
31° 30', 


Intermittent, 
Remittent, 


26 

6 


46 
12 


123 
33 


44 
12 


239 
63 




Both, 


32 


58 


156 


56 


302 


302 


Fort Mitchell, N. 
Lat. 32° 19', 


Intermittent, 
Remittent, 


30 

4 


20 
18 


60 
43 


33 

17 


143 

82 




Both, 


34 


38 


103 


50 


225 


225 


Fort Towson, N. 
Lat. 33° 51', 


Intermittent, 
Remittent, 


242 
16 


107 
37 


450 
114 


269 
30 


1068 
197 




Both, 


258 


144 


564 


299 


1265 


1265 


Fort Smith, N.Lat. 
35° 22', 


Intermittent, 
Remittent, 


190 



150 
5 


445 
98 


249 
24 


1034 
127 




Both, 


190 


155 


543 


278 


1161 


1161 



INTERIOR VALLEY OP NORTH AMERICA. 



21 



Twenty-six Posts. 




Quarters of the Year. 


Total 

of the 

Year. 


Comp. of 

annual 

iggregates. 




First. 


Second. 


Third. 


Fourth. 


Fort Gibson, N. 
Lat. 35° 57', 


Intermittent, 
Remittent, 


151 
12 


211 

19 


491 
161 


340 

50 


1193 
242 




Both, 


163 


230 


652 


390 


1435 


1435 


Jefferson Barracks, 
N. Lat. 88° 28', 


Intermittent, 
Remittent, 


32 

16 


63 

17 


152 
76 


75 

44 

Tf9~ 


322 
153 




Both, 


48 


80 


228 


475 


475 


Fort Leavenworth, 
N. Lat. 39° 20', 


Intermittent, 
Remittent, 


100 
1 


151 
3 


205 
16 


143 
10 


599 
30 




Both, 


101 
9 
6 


154 


221 


153 


629 


629 


Fort Armstrong, 
N. Lat. 41° 28', 


Intermittent, 
Remittent, 


70 
30 


72 
73 


30 
17 
47 


181 
126 




Both, 

Intermittent, 

Remittent, 


15 

7 
3 


100 


145 


307 


307 


Fort Dearborn, N. 
Lat. 41° 51', 


65 

2 


102 
4 


66 

2 


240 
11 




Both, 


10 


67 


106 


68 


251 


251 


Fort Gratiot, N. 
Lat. 43°, 


Intermittent, 
Remittent, 


46 
1 


286 
10 


333 
16 


110 
1 


775 
28 




Both, 


47 


296 


849 


111 


803 


803 


Fort Crawford, N. 
Lat. 43° 3', 


Intermittent, 
Remittent, 


13 


40 

2 


140 

32 


67 

7 


260 
41 




Both, 


13 


42 


172 


74 


301 


301 


Fort Niagara, N. 
Lat. 43° 15', 


Intermittent, 
Remittent, 


22 

18 

~40 


117 
20 


52 
62 


57 
20 


248 
120 




Both, 


137 


114 


77 


368 


368 


Fort Winnebago, 
N. Lat. 43° 31', 


Intermittent, 
Remittent, 


3 
4 


5 
10 


18 
3 


13 

7 


49 
14 
63 




Both, 

Intermittent, 

Remittent, 


7 


15 


21 


20 


63 


Madison Barracks, 
N. Lat. 43° 50', 


24 




98 



70 
20 


35 
8 


227 
28 




Both, 


24 


98 


90 


43 


255 


255 


Fort Howard, N. 
Lat. 44° 40', 


Intermittent, 
Remittent, 


2 
2 


11 

6 


28 
22 


10 
3 


51 
38 




Both, 


4 


17 


50 


13 


84 


84 


Fort Snelling, N. 
Lat. 44° 53', 


Intermittent, 
Remittent, 


2 



9 
3 


28 
11 


11 
3 


45 
17 




Both, 


2 


12 


34 


14 


62 


62 


Fort Mackinack, 
N. Lat. 45° 51', 


Intermittent, 
Remittent, 


7 
1 


37 
4 


16 
4 


16 
4 


76 
13 




Both, 


8 

1 


41 


20 


20 


89 


89 


Fort Brady, N. 
Lat. 46° 39', 


Intermittent, 
Remittent, 


16 



20 

2 


5 



41 
3 




Both, 


1 


16 


22 


5 


44 


44 



22 



THE PRINCIPAL DISEASES OF THE 



The British returns* are more limited, for the number of posts are smaller, 
and the range of country and climates less. They do not, moreover, give 
the relative number of cases in different seasons, or at the separate stations, 
and therefore express the prevalence of autumnal fever in Canada, generally, 
not in particular localities. 

TABLE 

Exhibiting the Annual Prevalence of Autumnal Fever among the British 

Troops in Canada. 

Ratio of cases to the mean strength of 1,000. 



Localities. 


intermit- 
tent 
Fever. 


Remittent 
Fever. 


Annual 

aggregate 

of both. 


Canada, between the latitude of 42° and 47°, 
from 1817 to 1836, inclusive— 20 years, - - - 


79 


5 


84 


Upper Canada, the principal Posts — Kingston, 
East end of Lake Ontario, N. Lat. 44° 8 / — To- 
ronto, North side of same Lake, in 44° 33 7 — Fort 
George, mouth of Niagara River, in 43° 15' — 
Amherstberg (Maiden), West end of Lake Erie, 
in 42° 10 7 — from 1818 to 1827, inclusive, - - 


178 


12 


190 


Lower Canada, principal ports on the River 
Richelieu, which connects Lake Champlain with 
the St. Lawrence, latitude from 45° to 46° — 
Montreal, latitude 45° 31', and Quebec, latitude 
4fi° 4-7/ _____________ 


26 


1 


27 





This table, by embracing the Peninsula north of Lakes Erie and Ontario, 
together with the banks of the St. Lawrence, down to its estuary, completes 
what the other left unfinished ) and enables us to estimate the relative pre- 
valence of autumnal fever, through every parallel of latitude, from the 
mouth of the Mississippi, to that of the St. Lawrence, and from Cape Flo- 
rida to G-ros Cap, at the entrance of Lake Superior. 

We should be aware, however, that the numbers in the tables do not 
always express, correctly, the cases of fever originating in the localities with 
which they stand in connexion. Thus, Maj. Tulloch, the compiler of the 
British Report, informs us that many of the cases of fever returned from 
the posts of Lower Canada, were relapses in patients from the posts of Upper 
Canada; and in the United States, our troops are often sent to more northern 
posts to recover from the fevers of the south j and thus by relapsing, add 
not a little to the number of cases at posts which otherwise might have 
presented but few. 

* Tulloch's Statistical Reports on the Sickness, Mortality, and Invalidizing among the troops in the 
United Kingdom, Mediterranean, and British America: prepared from the Records of the Army, Medi- 
cal Departments, and War-Office Returns, by command of Her Majesty, London, 1839. 



INTERIOR VALLEY OF NORTH AMERICA. 23 



SECTION III. 

CONDITIONS WHICH IMPOSE GEOGRAPHICAL LIMITS, AND GIVE UNEQUAL 
PREVALENCE TO AUTUMNAL EEVER. 

I. Soil. — Under this term I include all that composes the surface of 
the earth, apart from its waters. The loose upper stratum of our Valley 
consists, as far as its mineral elements are concerned, of the debris of the 
rocks beneath, or of deposits of the debris of other rocks, spread over the 
surface by ancient inundations. There are tracts of country, however, in 
which the rocks themselves appear at the surface. None of these conditions 
favor the production of autumnal fever ; but on the contrary, it prevails 
least where they are most perfectly developed ; and hence there is no reason 
for referring the disease to emanations from a purely mineral surface. 

The soil, however, may have another element than the mineral — dead 
organic matter, both animal and vegetable ; and this is its general character 
throughout the Valley. The amount of this element is very different in 
different places, for its production depends, first, on the fertility of the 
surface; second, on temperature; and third, on moisture. Where these 
conditions are all present, the growth of organic matter is redundant; where 
any one or more of them is wanting, it will be correspondingly limited. 
Thus it is small in quantity in the pine woods of the south (if we except 
the trees themselves), from the sandiness of the surface ; in the desert 
beyond the Mississippi, from the same cause, and also from the want of 
moisture; in the far north from the want of heat, yet it is abundant 
even beyond the limits to which the Fever extends ; on the Appalachian 
Mountains, from that deficiency in part, and from their rocky surface. 
Dead organic matter is, also, unequally distributed ; for the rains wash it 
down from the hills, and deposit it in the valleys ; where, adding to their 
fertility, it rapidly augments itself by promoting more luxuriant crops of 
vegetation. 

Now, it is a safe generalization to affirm that, all other circumstances 
being equal, autumnal fever prevails most where the amount of organic 
matter is the greatest, and least where it is least. A diligent study of the 
topographical descriptions of Booh I. Vol. 1. will sustain this conclusion and 
demonstrate that decaying organic matter is one of the conditions necessary 
to the production of autumnal fever. As to the mode in which it co-operates, 
two opinions may be entertained : First, It may supply the material out of 
which a poisonous gas is formed ; and, Second, It may be a nidus or hot-bed 
of animalcules or vegetable germs. In either case, we may presume that all 
kinds of decomposing organic matter, are not equally favorable to the pro- 
duction of the cause of this fever; but, although I have sought for facts 
bearing on this question, a sufficient number has not been found to justify 



24 THE PRINCIPAL DISEASES OF THE 

their presentation here. I hope the subject may attract the attention of 
others. 

The first breaking up of the soil appears, from a variety of observation, 
scattered through our topographical descriptions, to be frequently followed 
by autumnal fever ; and on the other hand, long-continued cultivation is 
accompanied by diminution of that disease ; the element which contributes 
to its production becoming exhausted. 

II. Living Vegetation. — Forests have been thought to modify the 
conditions which generate autumnal fever. Our medical topography sup- 
plies several facts, which go to show, that those who first penetrate our 
woods, and establish themselves in cabins, closely surrounded by trees, re- 
main comparatively exempt from autumnal fever, till the clearing is extended. 
On the other hand, it is a disease of the country, and especially of newly- 
settled parts, where the amount of forest is so great, as to maintain a high 
degree of humidity. Our cities and larger towns, it is well known, seldom 
suffer, and they are to be considered, as in some degree, presenting the very 
opposite condition from our woodlands. Again, trees have been thought to 
arrest the spread of that gaseous agent, whatever it may be, which is said 
to be the true cause of the Fever; but in what manner they do it, no one 
can tell. It has been conjectured, that their leaves absorb the noxious ex- 
halation; and also that they mechanically arrest the dissemination of the 
aerial poison. In harmony with the former hypothesis, is that of Dr. Cart- 
wright (seeVol. I. p. 79), in reference to the Jussieua grand/flora, and some 
other aquatic plants, in the delta of the Mississippi ; which, he supposes, ab- 
sorb the agent that produces autumnal fever. I have already expressed the 
opinion, that the facts do not establish that hypothesis ) and must here in 
conclusion, remark, that living vegetation is so mixed up with other condi- 
tions, necessary to the production of the Fever, that, in the existing stage 
of observation, its effects cannot be correctly estimated. 

III. Surface Water. — In the maritime parts of Florida, Alabama, 
Mississippi, Louisiana, and Texas, surface water is abundant, for one side of 
each rests on the G-ulf, which has many inlets and little bays, the banks of 
which are inhabited. The rivers, moreover, are numerous, and as they 
approach the Gulf, expand into broad estuaries or deltas. The delta of the 
Mississippi abounds in lakes, lagoons, and bayous. As we ascend this, 
and the smaller rivers, wide cypress and liquidambar swamps, annually re- 
plenished, skirt both sides. The intervening plains are cut up by smaller 
streams, which have wide alluvions, often subjected to inundations ; and the 
country between them abounds in swamps ; from which even the sandy pine 
plateaus are not entirely free. This continues to be their condition, till we 
reach the flanks of the Cumberland Mountains, on the east, and those of the 
Ozark Hills to the west. As we ascend the Mississippi, to the mouth of 
the Missouri, we find its annual floods leaving small lakes, ponds, swamps, 
and lagoons ', which in the aggregate are of great extent, and but partially 



INTERIOR YALLEY OF NORTH AMERICA. 25 

drained or dried up, before the next inundation. Now, as we have seen, the 
whole of this region is infested with autumnal fever, beyond any other por- 
tion of the Valley. 

In North Alabama, Tennessee, and Kentucky, swamps are almost unknown, 
except along the few rivers, which have wide bottom-lands, most of which, 
moreover, are exempt from inundation. The rivers, however, are sinuous, 
and in summer, sluggish and pondy ) and it is in their vicinity, chiefly, that 
autumnal fever prevails. In the states of Illinois, Indiana, and Ohio, the 
rivers generally flow through wide valleys, many of which are liable to be 
overflowed. Small lakes, ponds, and swamps, are also frequent, in certain 
portions of those states ; and it is precisely these localities, which are most 
infested. To the east of all the states mentioned, as we climb the mountains, 
the surface water is no longer found in basins ; and the streams, generally, 
have a rapid current, down narrow and rocky channels ; and here, autumnal 
fever nearly disappears ) or, when present, is confined to the valley of some 
stagnating stream. Everywhere, west of the states of Arkansas, Missouri, 
and Iowa, surface water is scarce ; the declivity of the plain which stretches 
from the Rocky Mountains, favoring its escape; while the subjacent sand 
almost absorbs even considerable rivers. Thus, as we advance into that 
desert, we come at the same time to the limits of surface water, and of au- 
tumnal fever. In the north there is no deficiency, for the whole country is 
essentially lacustrine ; and up to a certain latitude, the Fever prevails. Thus 
the shores of Lake Ontario and Lake Erie, with those of the southern ex- 
tremity of Huron and Michigan, are infested, and sutler far more than the 
drier lands which surround them. But beyond these limits, on the shores of 
the two latter lakes, and on those of Lake Superior, the Fever, as we 
have seen, is never epidemic, although water is abundant ; and still further 
north, where small lakes, and their connecting streams, exist in countless 
numbers, the disease is unknown ; showing that, while water is essential 
to the production of this Fever, other causes must co-operate to give it 
power. 

Let us inquire into the modus operandi of this agent in the production of 
the disease under consideration. 

1. Under the influence of solar heat it impregnates the air with vapor, 
giving a high dew point; and other circumstances being equal, the evapo- 
ration is greatest where the heat is highest. This, of course, is in the 
southern part of the Valley, and there, as we have seen, the Fever prevails 
most. 

2. Surface water not only contributes largely to the production of a luxu- 
riant vegetation, destined annually to perish, but is indispensable to the 
decomposition of what it has aided in producing. Hence, without its agency, 
none of the deleterious gases, which are supposed to be thus generated, 
could have an existence. But its presence in any or all quantities, will not 
answer equally well. If there be too little, the molecular movements of 



26 THE PRINCIPAL DISEASES OE THE 

fermentation are arrested for want of a solvent — if too much, the atmo- 
sphere, indispensable to the process, is excluded ; or the evolved gases are 
absorbed and retained. 

3. Its presence is essential to those chemical actions, in certain soils, 
which are believed, by some writers, to generate exhalations that occasion 
the Fever. 

4. It is equally indispensable to the production of both animalcules and 
microscopic plants. 

5. Both evaporation and condensation are known to be accompanied by 
electrical perturbations. 

Thus water is a necessary element, in all the hypotheses which have been 
framed to account for autumnal fever. 

But a contrary and salubrious influence has been ascribed to water ; for 
it is held by many that this fluid absorbs the noxious gas or gases, which 
they believe to produce the Fever, and thus limits its prevalence. According 
to this opinion, the deep water in the centre of a basin, may imbibe and retain 
the noxious gases, which the shallow waters of its margins have contributed 
to generate; and, in support of the hypothesis, it has been affirmed that the 
vicinity of cataracts and rapids is more unhealthy than the banks of the 
rivers in which they occur. The absorbed gases are supposed to be there 
liberated by the agitation of the water. The medical topography of Book I. 
Vol. I. presents several facts bearing on this hypothesis. Thus Wetumpka, at 
the foot of the long rapids of the Coosa River; Louisville, at the falls of the 
Ohio River; and Maumee City, at the termination of the rapids of the Mau- 
mee River, are all infested with autumnal fever ; but other towns, on the 
same rivers, are likewise scourged with that disease ; and Oswego River, 
which drains the Montezuma swamps of Western New York, has at its mouth 
a great number of mills, yet the inhabitants suffer but little from that 
disease. It prevails still less at the Falls of Niagara ; and finally, at Zanes- 
ville, where a natural waterfall has been augmented by artificial means, and 
on the Kentucky River, where there are series of pools and dams, there is 
no special prevalence of the Fever. Thus the facts furnished by our Valley, 
do not prove that waterfalls eliminate a gas which is the cause of the disease 
under consideration. 

IV. Temperature. — The fact that autumnal fever prevails perpetually 
and virulently, within the tropics, but ceases long before we reach the polar 
circle, demonstrates that a high temperature is one of the conditions neces- 
sary to its production. Should it be ascribed to heat alone ? The answer 
must be in the negative; for places having the same temperature, but vary- 
ing in other conditions, are very differently affected with autumnal fever. 
Thus the people of Mobile Bay suffer greatly, while those who live on the 
adjoining oak and pine terrace escape; and the summer heat of the southern 
portions of the great desert is intense, but those who traverse it, and keep 
at a distance from its water-courses, pass the season unaffected. It cannot 



INTERIOR VALLEY OF NORTH AMERICA. 



27 



be affirmed, that the direct action of a hot atmosphere on the body, does not 
contribute to the production of the Fever j for, on the contrary, where it 
prevails as an epidemic, exposure to the noon-day summer sun is often fol- 
lowed by an attack j but such exposure, in a different locality, will not pro- 
duce it ; and, therefore, we may conclude that in its direct action, heat is 
merely an exciting cause, on which it is not necessary to expatiate in this 
place ; and I will therefore proceed to trace out all its indirect effects. 

Our army statistics furnish some instructive facts on this point. The posts 
which lie along the Mississippi, are placed nearly under the same conditions, 
in everything but temperature, which varies according to their latitude. 
They are, therefore, well fitted to indicate the influence of this climatic con- 
dition in the production of the Fever. Its relative prevalence at these posts, 
which extend through more than thirteen degrees of latitude, is presented 
in connexion with the annual and quarterly mean heat, in the first part of 
the following table, while the second offers a comparison of two posts in the 
region west of the Mississippi, and the third of two on the Lakes. 



TABLE. 



g'3, 

a -s .2 






03 "3 



Posts. 



Baton Rouge, - - - 

Jefferson Barracks, - - 

Fort Armstrong, - - 

Fort Crawford, - - - 

Fort Snelling, - - - 



30 36 
38 28 
41 32 

43 03 

44 53 



824 
475 
307 
301 
62 



e3 >- 
e Hi 



67.56 
56.93 
50.65 
47.35 
45.15 



52.68 
33.98 
25.15 
20.69 
17.29 



68.72 
56.55 
50.82 
48.25 
46.56 



^S 

^s 



81.48 
76.19 
74.57 
72.38 
71.16 






67. 

54.38 

52.07 

48.09 

45.59 



^Ph 



Fort Gibson, - - - 
Fort Leavenworth, - 



35 48 1435 61.07 42.50 
39 23 629152.34 27.60 



61.26 79.17 61.53 
53 38 74.00154.39 



a 2 « 



Fort Dearborn, 141 50 251 

Fort Brady, |46 30 44 



46.14 24.31 
40.62 18.06 



45.39'67.80 47.09 
38.17'62.14 44.13 



To show, by a comparison of localities, the exact relation between tempera- 
ture and autumnal fever, the conditions of the different places should, in 
all other respects, be alike, which is not often the case : nevertheless, the 
medical topography and hydrography of the posts, compared together in the 
foregoing table, will be found substantially the same, and they show, that 
with the decrease of yearly and summer heat, other conditions continuing 
unchanged, there is an abatement of the Fever. It is, however, with the 
heat of summer, and not that of the year, that autumnal fever is connected; 
and the question here arises, what summer temperature is necessary to the 
production of the Fever ? This question cannot be rigorously answered ; 
for the number of observations hitherto made, in the proper region, is too 
small to justify a positive conclusion ; we may, however, assume, that a 
summer temperature of sixty degrees, is necessary to the production of the 



28 THE PRINCIPAL DISEASES OF THE 

Fever ; and that it will not prevail as an epidemic, where the temperature of 
that season falls below sixty-five; finally, that if the other conditions favor- 
ing its production are deficient, it will cease before those reductions of tem- 
perature have been reached. 

According to these conclusions, the Fever will occur in winter, at all places 
where that season has a mean temperature of sixty degrees or upward ; as 
at Vera Cruz, Tampico, Havana, Key West, Tampa Bay, and Fort King, as 
may be seen in the table ( Vol. I. p. 487) ; and it is well known that cases do 
occur at those places, in that season ; but at the two latter posts, where the 
winter heat barely rises over sixty, they are few in number. At New Or- 
leans and generally under the thirtieth parallel, where the mean winter heat 
is as low as fifty, the Fever is suspended. But the seasons are made up of 
months, and we are here brought to consider its connexion with their re- 
spective temperatures. 

Up to Tampa Bay, every winter month rises above sixty degrees ; but at 
New Orleans, or the thirtieth parallel, only the nine months from March to 
November, have that temperature; and as we advance to the north, the 
number of months having it constantly decreases. Thus, at St. Louis, it is 
attained by five months only — from May to September, inclusive; at Fort 
Snelling, by four ; at Fort Brady, by three ; at Montreal, by four; at Quebec, 
by three. In advancing further north, June and September fall below it ; 
and, finally, in the distant north, July and August, or the entire year. Long 
before this reduction is reached by those two months, however, the Fever 
ceases; and therefore it results, that a continuance for more than two months 
of a heat equal to sixty degrees, is necessary to the development of the 
Fever. Hence we can understand, why it prevails more in October than April, 
although their mean temperatures are nearly the same; in November than 
June, notwithstanding the latter is much the warmer month, and in Sep- 
tember and August, than July — the hottest month of the year. The 
greatest prevalence in every latitude, is indeed, generally some weeks, after 
the hottest month ; showing that the effects of temperature are cumulative. 
It appears from all that has been said, that within the tropics, autumnal 
fever may occur throughout the year ; and that as we move northerly, the 
duration of its prevalence shortens, by its beginning later in spring, and 
terminating earlier in autumn. March and November first escape ; then 
April and May on the one hand, and October on the other — lastly, June 
and September. 

In contemplating the climatic relations which exist between autumnal 
fever, and certain aspects of vegetation, we find that in the tropical regions 
they are the same throughout the year, and that when we attain the thirty- 
third parallel, which constitutes the northern limit of several southern trees 
and plants, the prevalence of the Fever is for a much shorter period ; that its 
disappearance is nearly at the same curve, at which the miscellaneous vege- 
tation of the middle latitudes, gives place to the terebinthinate trees and 



INTERIOR VALLEY OF NORTH AMERICA. 29 

birches, of the north ; finally, that maize or Indian corn, which grows all 
the year round, in the tropical regions, finds the summers too short for the 
ripening of its grain, in nearly the same curve of summer temperature, at 
which autumnal fever is arrested. 

If change of latitude, by diminishing the heat of the atmosphere and that 
of the earth's surface can, as we have just seen, arrest the production of 
autumnal fever, an increase of elevation above the level of the sea, may 
likewise do it. Thus the Fever which scourges the tierra caliente of 
Mexico, near the level of the sea, is almost unknown in and around the city 
of Mexico, at an elevation of seven thousand four hundred and fifty feet, 
although the latitude remains the same. The inhabitants among the 
sources of the Kenawha and Tennessee Rivers, on the Appalachian Moun- 
tains, at a medium elevation of nearly three thousand feet, are almost 
exempt, while those who occupy the valleys, under the same parallels, are 
affected ; and, further north, at half that elevation, where the Alleghany 
and Genesee Rivers have their sources, the disease is almost unknown, 
while on the shores of Lake Ontario, directly north, it prevails. In travers- 
ing that mountain terrace, which has a mean summer temperature of sixty- 
three degrees, I witnessed a frost, on the night of the second of August, 
which destroyed the Indian corn ; but, on descending into the valley of the 
G-enesee, which, although a degree further north, is infested with the Fever, 
the fields of maize were uninjured. Finally, the constantly increasing eleva- 
tion of the desert to the west of the Mississippi is, no doubt, one cause of 
the disappearance of the Fever under the same parallels, in which it prevails 
on the banks of that river. 

Having established the paramount influence of high temperature in the 
production of autumnal fever, it remains to inquire into the modes in which 
it may operate. I have already referred to its effect as an exciting cause, 
but this view is too limited, and others must now come under consideration. 

1. The long-continued impress of summer heat upon the surface of the 
body, occasioning copious perspiration, and through the nerves of the skin 
sympathetically affecting the internal organs, more especially the abdominal, 
may predispose to this form of fever; and the cool nights of early autumn, 
acting on the same surface, may still further derange the economy. That 
such nights, and occasional sudden changes of temperature, are often followed 
by an immediate development of the Fever, is well known. 

2. Heat promotes great evaporation from all moist and watery surfaces, 
thus giving to the atmosphere a high dew point. 

3. It favors the fermentative decomposition of organic matter, and the 
production of new compounds. 

4. It facilitates the multiplication of minute but visible animals, and 
cryptogamic plants, and may be presumed, therefore, to multiply the micro- 
scopic — both animal and vegetable. 

5. It evaporates the superfluous water of ponds, swamps, marshes, and 






SO THE PRINCIPAL DISEASES OF THE 

lagging streams ; thus bringing them into a condition favorable to the more 
rapid decay of the organic matters which they contain or cover over, and 
thereby promoting the extrication of gases. 

6. It dries the surface of the ground after the rains of spring and sum- 
mer; and may (as has been asserted) cause it, in the act of desiccation, to 
send forth deleterious exhalations, different from those generated in deposits 
of decomposing organic matter. 

7. It disturbs the equilibrium of the electricity of the atmosphere; hence 
summer thunderstorms are of almost daily occurrence, on the coasts of the 
Gulf of Mexico; but on the shores of Lake Superior they are rare. 

Thus solar heat plays an indispensable part in every hypothesis which has 
been proposed to explain the origin of autumnal fever ; answering equally 
1 well for the advocates of combined heat and moisture — miasmatic exhala- 
tions, microscopic beings, and atmospheric electricity. 

We have now reviewed all the obvious conditions which seem to concur 
in the production of our autumnal fever, and endeavored to assign the modus 
operandi and influence of each. We have seen the necessity of their con- 
currence, from the fact that the absence of any one puts an end to the pre- 
valence of the Fever. These conditions are dead organic matter, resting on 
or blended with the mineral elements of the soil ; water, not in any, but a 
certain quantity ; and temperature, above the sixtieth degree, continuing for 
at least two months. And here we might stop, but for the instinctive pro- 
pensity of the human mind to arrive at the knowledge of a single efficient 
cause ; to which, therefore, a chapter must be devoted. 



CHAPTER II. 

SPECULATIONS ON THE EFFICIENT CAUSE OF AUTUMNAL FEVER. 



SECTION I. 

METEORIC HYPOTHESIS. 

It has been suggested, and, indeed, is believed by some physicians, that 
while the three conditions recognised in the last chapter, are present wher- 
ever autumnal fever prevails, but two of them — heat and moisture — exert 
an influence in its production. Under the joint influence of these elements, 
vegetation will of course flourish and decay; but not contribute to 
the production of the Fever. The advocates of this opinion, of course, 
deny the existence of a special poison ; and ascribe the disease to the direct, 
combined action of a hot, humid, and electrical atmosphere. The discussion 



INTERIOR VALLEY OF NORTH AMERICA. 31 

of this hypothesis, necessarily involves to some extent, the discussion of the 
question of a special agent ; for but the two opinions can be held. The 
Fever prevails extensively, is often epidemic, and is not contagious ; it must 
have a cause, and if that cause be not some conjunction of the ordinary 
elements and sensible qualities of the atmosphere, it must be a poison, dis- 
solved or suspended in it. If it should appear, then, that the Fever does not 
depend on the former, we may affirm that it does depend upon the latter. 

I have already shown that neither heat nor moisture, by itself, can pro- 
duce the Fever, and will now proceed to state certain objections to the hypo- 
thesis that it results from their combined influence. 

1. It is well known, that autumnal fever seldom appears on board of 
vessels which cruise in the Gulf of Mexico, although the air, at the tempera- 
ture of eighty, is nearly saturated with vapor. 

2. The inhabitants of Key West, who breathe a similar atmosphere, are 
much less afflicted with the Fever, than those on the peninsula of Florida, 
several degrees further north. Now although that little island supports 
considerable vegetation, its swamps are filled with the waters of the Gulf in 
every high tide, and when strong winds prevail.* 

3. The sandy banks of Pensacola Bay, from its entrance, up to the town 
of Pensacola, suffer but little ; while, at the head of the bay, where exten- 
sive alluvial deposits have been made, the Fever has been so constant and 
fatal as to prevent permanent settlements. Yet the temperature and mois- 
ture of both localities are the same, for they are but ten miles apart. f 

4. The pine woods around the Gulf of Mexico, at the distance of only two 
or three miles from the estuaries of the rivers, are places of retreat from 
the Fever, although there is a sea and land breeze, which tends to equalize 
the humid atmosphere. 

5. The inhabitants of the Balize, suffer less from the Fever than those 
along the rivers of the interior of Louisiana, two or three degrees further 
north ; notwithstanding they are immersed in an atmosphere of great heat 
and vapor. Vegetation is as luxuriant at the Balize as above ; but when it 
dies, it falls upon a soil impregnated with sea salt, and is often wetted by 
the waves of the Gulf. 

6. In many parts of Kentucky and Tennessee, where the surface is dry 
and ridgy, and the streams narrow and tortuous, the Fever occurs upon the 
former, although the atmospherioJiumidity is small. 

7. It is well known that a family may settle down in the forest, and culti- 
vating but a small spot, remain free from fever ; but when several families 
arrive, and an extensive breaking up of the soil takes place, it immediately 
begins to prevail, although the heat and moisture are not thereby increased. 

8. Dr. Winter gave me the following fact. On Cedar Creek, a tributary 
of Cumberland River, a mill-dam had been erected about sixteen feet high. 
After twenty-two years, the basin above having become filled up with silt 

* See Vol. I. p. 47. f See Vol. I. p. 52. 



32 THE PRINCIPAL DISEASES OF THE 

and drift, the dam was torn down, and the perpendicular face of the deposit 
exposed to the action of the sun and air, in the month of August. The 
consequence of this was, that nearly all the men who performed this labor, 
were seized with severe autumnal fever, and one of them died. There was 
no pond above, nor any marsh in the neighborhood; and the people gene- 
rally were healthy at the time. Here there was no combined agency of heat 
and moisture ; and hence the facts afford strong evidence of a developed 
aerial poison. 

9. On Paint Creek, Ohio, a mill-pond was generally drained the first of 
June, and the rains of that month washed away the silt and dead plants and 
animals; so that the people of the adjoining village of Washington suffered 
but little from the Fever; the draining was postponed till July, and no rains 
followed to wash out the basin. Then there immediately followed an epi- 
demic autumnal fever, which prevailed most on the side of the village next 
the pond. More than a fourth of the population suffered an attack, and 
nearly three per cent, of the whole number of inhabitants perished.* 

10. It has frequently happened, that individuals who have lodged for a 
single night in certain localities, have after several days, or even weeks, been 
taken down by the Fever. "j* More than this, persons, living in places where 
it never originates, have been seized in the spring with intermittents, after 
having in the preceding autumn, travelled where the Fever prevailed. Now 
it is in no degree characteristic of heat and moisture, to produce remote 
effects. A catarrh, a pleurisy, or a rheumatism, comes on soon after ex- 
posure, or not at all. The development of the disease, at a distant time 
from that at which the remote cause was applied, clearly suggests, that the 
cause was something else than a particular condition of the sensible pro- 
perties of the atmosphere. 

11. At our different salt works, the operatives spend their lives in a hot 
atmosphere saturated with vapor; and yet, on the whole, are more exempt 
from fever than the surrounding population. \ 

12. Lastly, in some of our manufacturing establishments, the indoor arti- 
sans and operatives, labor in a heated atmosphere supersaturated with vapor, 
but remain free from autumnal fever. 

These facts seem to me conclusive in their bearing against the meteoric 
hypothesis ; except so far as certain atmospheric conditions may act as ex- 
citing causes ; and we are, therefore, thrown upon the alternative, — a dele- 
terious agent, diffused in the atmosphere ; the positive existence of which 
seems to me to be established, by the facts which have been cited. 

Now this agent may be either one, of two kinds — inorganic or organic — 
and both have a prima facie advantage over the hypothesis we have exa- 
mined, in demanding the concurrence of all the conditions — heat, water, and 
dead vegetable and animal forms— which have been shown to be always 
present, wherever autumnal fever prevails ; while the last is left out of ac- 

* See Vol. I. p. 294. f See Vol. I. p. 370. % See Vol. I. pp. 261 and 404. 



INTERIOR VALLEY OF NORTH AMERICA. 33 

count by the meteoric hypothesis. We must first inquire into the origin 
and nature of the inorganic poison. 



SECTION II, 

MALARIAL HYPOTHESIS. 

I. It is unnecessary to inquire into the nature of the gases, which may 
be exhaled from an earthy surface, consisting of nothing but the fragments 
and powder of the subjacent rocks, and the different salts, or oxides, formed 
by their decomposition, under the influence of heat, water, and atmospheric 
air; for no such surface exists in our Valley. Whenever the rocky strata 
are thus exposed, they begin to crumble ; and the pulverulent layer then 
immediately becomes the nidus of some kind of plant; thus, lichens 
overspread the hardest rocks, and, by their death and decay, add to the 
thin layer of mineral matter, an organic element, at once vegetable and 
animal in its composition. In this way, the spot becomes prepared for a 
vegetation of a higher order, which, in turn, augments the amount of 
organic matter; while the rock beneath, by continued disintegration, 
continues to contribute new mineral substances. Thus it is, that the loose 
upper crust of the earth is accumulated; and the nearer we come to the 
actual surface, the greater, in proportion, are organic elements, or those 
fixed compounds which are formed by its decomposition. The soil thus 
formed may vary exceedingly in its depth ; for where the rock has under- 
gone rapid disintegration, or the debris have favored a luxuriant vegetation, 
the soil will be much deeper, than in opposite circumstances; but there is 
still another source of inequality. The soils thus formed are not fixed, and 
consequently are liable to be drifted about by currents of water. In 
ancient times, great portions of the Valley, on the north side of the Ohio 
River, were deeply covered with this kind of drift or diluvium : and down 
to the present time, every considerable rain or dissolving snow, but 
especially the former, washes a portion of the soil, with its superincumbent 
dead plants and animals, into the valleys, where they are speedily deposited. 

But the soil of every habitable part of the Valley has, at all times, 
resting on its surface, a layer of dead and decomposing organic matter ; 
which is abundant in proportion to its fertility, and its favorable exposure 
to rains and the heat of the sun — that is, to those conditions which cherish 
the growth of animals and vegetables. 

Now, in the study of medical topography, with reference to autumnal 
fever, our attention has been generally directed to this layer only ; and as 
there may be some physicians who even doubt the existence of those 
organized and decaying forms, in the soil beneath, supposing that they 



34 THE PRINCIPAL DISEASES OF THE 

suffer decomposition when they disappear from the surface, it may be well 
to say something more on this subject. \ 

The soil of which the analyses are given at pages 75, 76, and 293 ( Vol. I.), 
all contain organic matters, which, in one, more than equal all the inorganic 
substances. One of the specimens examined was silt, taken from a point 
ten feet below the surface, in New Orleans ; and Professor Riddel found that 
nearly one-fourth consisted of "■ organized matters, such as the sporules or 
germs of algse, animalcules, and their ova ;" and at the depth of sixteen feet, 
in sinking the gas tanks of that city ( Vol. I. p. 76), wood was found which 
had the texture of cheese, when the spade passed through it. The length of 
time required for the Mississippi to deposit the sixteen feet of superincum- 
bent silt, must have been indefinitely long. Again : in parts of Ohio, where 
there is a deep diluvial or post-diluvial deposit, when wells are dug, plants 
unknown in the neighborhood often appear upon the earth which had been 
thrown out, and doubtless spring from seed, which had lain buried for an 
immense length of time. Still further : where the upper crust is composed 
of sand, but produces the kinds of vegetation that can grow on such a sur- 
face, the decaying organic matter is washed into the ground by rains. 
Thus it is that the manure or mould, that is spread on the white sands of the 
gardens of the navy yards at Pensacola Bay, rapidly disappears. In this 
way, a spot which seems destitute of dead organic matter, may have an 
admixture of that element below the surface. From these facts, we are 
warranted in reaffirming, that the soil and subsoil, of all parts of the Interior 
Valley, contain organic matter, in every stage of decomposition. 

II. We come now to consider the dead and decaying organic matter 
deposited on the surface. This does not consist of vegetable forms merely 
as we too often suppose, but likewise of animal. An inspection with the 
naked eye, and still more with the microscope, reveals to us that innumera- 
ble insects, and other minute animals, live and perish among vegetables. 
Many tribes, moreover, find their sustenance and abode in the decaying 
remains of plants. Still further, the surface and superficial parts of the 
ground teem with small quadrupeds, reptiles, and worms; while the trunk 
of every fallen tree, in a certain stage of its decay, abounds in various kinds 
of grubs or larvae. From the mouldering remains of trees and other vege- 
tables, moreover, spring mushrooms, algee, lichens, and other cryptogamic 
plants, which abound in nitrogen beyond the higher order of vegetables, and 
have, in fact, nearly the same chemical elements with animals. Finally, 
wherever there are pools, or swamps, or running streams, there are fishes, 
molluscse, and crustacese, which multiply and perish, and whose bodies then 
float and dissolve, or sink to the bottom, or are thrown upon the shores, and 
mingled with the remains of land animals and plants. Thus, a vegeto- 
animal layer overspreads the surface of the country : and under the com- 
bined influence of water, heat, and air, when the two former are in the right 



INTERIOR VALLEY OF NORTH AMERICA. 35 

proportions, is constantly undergoing decomposition, and originating new 
chemical compounds. 

III. But the organic covering of the surface is, by no means, of the 
same nature in every locality. We cannot tell what kind of plants and 
animals, in past ages, left their remains on what now makes our subsoil ; 
but the existing forms are subjects of observation, and, in the investigation 
which occupies us, should not be entirely overlooked. 

1. The trees, in what are called the pine woods of the South, are chiefly 
resinous, and abound in hydrogen. Vegetable matters having such a com- 
position are little disposed to pass into fermentation, but are decomposed by 
the slow combustion of several of their principles, by the oxygen of the 
atmosphere; and if the efficient cause of autumnal fever be a gas, formed 
during the fermentative decomposition of organic matter, we have here one 
explanation of the comparative absence of that fever in those woods. 

2. The Graminese, Equisetacea, and indeed, all kinds of grasses, contain 
in their culms and blades a great quantity of silicate of potash, and in their 
seed much phosphate of magnesia and lime. They undergo decomposition 
very slowly, and the results cannot be the same as those of plants widely 
differing from them in composition. In describing the medical topography of 
the Balize ( Vol. I. p. 90), the extensive and luxuriant growths of the Plirag- 
mites communis, Typha latifolia, and Scirpus lacustris were mentioned; and I 
have already conjectured that their falling, when dead, into brackish water, 
may modify their mode of decomposition ; but we may also believe that their 
composition exerts an influence ; and that, on the hypothesis that the Fever 
is the offspring of the decomposition of organic matter, one cause of its 
milder prevalence, at the final termination of the Mississippi, than along the 
same river above, may be the peculiar composition of its reigning vegetation. 
Again : the vegetation on the grand prairies, beyond the Mississippi, is 
chiefly gramineous, and to this, on the same hypothesis, we might, perhaps, 
consistently attribute some portion of their exemption from the Fever. 

3. The oak tree abounds in tanno-gallic acid, and is often the governing 
tree in considerable tracts of forest; which, I think, are less infested with 
the Fever than localities having a diversified, arboreous vegetation. At all 
events the exuviae of such a forest might be expected to afford the elements 
for gaseous exhalations of a different sort from those of pine, or of trees not 
abounding in that acid. 

4. The Leguminosae, including all kinds of pulse, as peas, beans, and 
lentils, contain very little potash, silica, or the earthy phosphates, while they 
abound in nitrogen, and must, therefore, while under decomposition, yield 
gases of a very different kind from the Graminese. 

5. The extensive natural family of plants called the Grucifera, embracing 
the radish, mustard, turnip, and cabbage, contain sulphur and nitrogenized 
ingredients, fitting them to give out, in decomposition, gases varying from 
the last. 



36 THE PRINCIPAL DISEASES OF THE 

6. Not to pursue the subject any further, the fungi, boleti, and other 
cryptogamic plants, which abound in dark and shaded woods have, as already 
indicated, a composition almost animal, and cannot, in their spontaneous 
decay, afford results of the same kind with plants of a widely different com- 
position.* 

IY. The facts which have been cited teach us that there is, mingled with 
the soil or resting upon it, a great amount and endless variety of organic 
matter, both animal and vegetable, to the decomposition of which, and to 
the resulting new compounds, the malarialists look for the efficient cause of 
autumnal fever. In doing this, a special stress may, with great propriety, 
be laid on a few unquestionable facts. 

1. That, all other circumstances being equal, the Fever prevails most where 
the organic matter is most abundant, in or resting on the soil. 

2. That where the surface is not moist enough to favor the decomposition 
of organic matter, the Fever has but little prevalence. 

3. That a temperature of sixty degrees of Fahrenheit, or above, is necessary 
to fermentation and putrefaction, and that the Fever ceases, in going north, 
when we reach a summer temperature below that degree. 

4. That particular localities have experienced the Fever, in an epidemic 
form, when a surface abounding in organic matter has been newly exposed 
to the action of the summer sun. 

5. That under long cultivation, which exhausts the organic matter of the 
soil, and prevents its accumulation on the surface, the Fever almost ceases to 
appear. 

Y. These facts undeniably establish a connexion between a certain con- 
dition of the surface and autumnal fever ; but they do not prove the exis- 
tence of malaria, or a gas, which is the efficient cause of the Fever, and to 
this point we must now give attention. 

1. The observed aeriform products of this decomposition are carbonic acid, 
carbonic oxide, carburetted hydrogen, sulphuretted hydrogen, and carbonate 
of ammonia. Now, there is not a single fact going to show that either of 
these gases can produce autumnal fever. On the contrary, as the result of 
experience, it may be safely affirmed, that they do not; for the effects which 
follow an exposure to them are of a different kind. But it can be said that, 
in the endless variety of new compounds, which nature may form out of the 
ultimate elements of plants and animals, there may be many which have 
not yet been detected, and that some one of these is the efficient cause of the 
Fever, and this cannot be denied. But we must not forget that it is an 
assertion without proof — a mere suggested hypothesis — a proposition to 
be proved. 

2. It is well known to us all, that there are sickly and healthy seasons at 
the same place, and sometimes over large portions of our Valley, while the 

* Liebig : Chem. applied to Agricul. and Phys. 



INTERIOR VALLEY OF NORTH AMERICA. 87 

amount of organic matter remains unchanged ; and, as yet, it has not been 
shown that this can be explained by a reference to varying degrees of heat 
and moisture, though the subject has not received sufficient attention to show 
that it cannot. 

3. The Fever occasionally appears in limited localities, from which it is in 
general entirely absent; the surface meanwhile remaining, to all observation, 
precisely the same. 

4. All the known gases are either simple bodies, as hydrogen and chlorine, 
or binary compounds of two simple elements, as carbonic acid, ammonia, and 
carburetted hydrogen, and their principles are united in definite proportions, 
giving to each a uniform and peculiar character. If we may depend on 
analogy, the assumed undiscovered gas, called malaria, must be of the same 
character; and, therefore, at all times and places be productive of the same 
effects. Now although autumnal fever is a disease of intrinsic uniformity, 
it shows modifications which have not been explained by the assignment of 
modifying causes; and without such causes, its diversities constitute an objec- 
tion to the existence of a single agent of an unchangeable character. 

On the whole, therefore, I must repeat, that while the conditions under 
which our autumnal fever appears, are sufficiently clear to observation, the 
existence of a special gaseous agent, resulting from them, remains to be 
proved. 

SECTION III. 

VEGETO-ANIMALCULAR HYPOTHESIS. 

I have united two words to express an hypothesis which ascribes 
autumnal fever to living organic forms, too small to be seen with the naked 
eye j and which may belong either to the vegetable or animal kingdom, or 
partake of the characters of both. 

In the year 1832, I published in the Western Medical and Physical 
Journal, of which I was the editor, a series of papers on Epidemic Cholera, 
which were afterward collected and enlarged into a small volume ;* in which 
an attempt was made to show, that the mode in which that disease spreads, 
was more fully explained by the animalcular hypothesis than any other 
which had been proposed. The brief investigation then given to the sub- 
ject, reinspired my respect for the opinion long before expressed, that 
autumnal fever, and many other forms of disease, might be of animalcular 
origin ; and the discoveries since made by the Ehrenberg school, have 
seemed to render that doctrine still more probable. But I have neither had 
time nor means for experimental or bibliographical inquiry; and do not 
propose to dwell very long upon the subject in this place. 

As applied to Epidemic Cholera, 1 regard the hypothesis of animalcules 
as more plausible than that of vegetable germs; but in reference to 

* A Practical Treatise on the History, Prevalence, and Treatment of Epidemic Cholera. By Daniel 
Drake, M.D. Cincinnati : 1832. Pp. 180. 



38 THE PRINCIPAL DISEASES OF THE 

autumnal fever, either may be assumed; and in support of the assumption, 
I proceed to make the following observations : 

1. The microscope has revealed the existence of a countless variety of 
organic forms, which surround and penetrate the bodies of larger animals 
and plants, whether living, or dead and decaying, inhabit all waters, salt 
and fresh, and swarm in the atmosphere ; buoyed up and moving by their 
own organs, or sustained by their levity, and wafted about by currents of 
air. The difficulty of detecting them in the atmosphere is greater than in 
water, or when attached to solid substances ; but to my own mind, it seems 
probable that they exist in the aerial ocean in greater multitudes than else- 
where. For, first, minute particles of matter, organic and inorganic, are 
at all times floating in that ocean, and may serve as their food or resting- 
places ; and, second, as the surface of a body becomes greater in com- 
parison with its weight, the more it is reduced in size, it follows that living, 
organic forms, both animal and vegetable, may be of such size, as to float 
permanently in the air. The power of reproduction, possessed by these 
microscopic creatures, is still more wonderful than their minuteness. It 
exceeds, indefinitely, all examples presented by the visible organic kingdom ; 
where, however, we see the government of the same law, for, in both plants 
and animals, the small multiply more rapidly than the large. In contem- 
plating the invisible living world, in which the visible is, as it were, 
immersed, the mind becomes bewildered, as in meditating on the infinite, 
and requires to fall back upon obvious facts. Now one of these facts is, 
that whole rock formations, of great thickness and extent, have been found, 
under the microscope, to be composed entirely of the silicious shells or 
coverings of animalcules. In such beings, the increase seems to be merely 
by secretion from, or division of the parent body. 

2. Among visible plants and animals, there are species that form no 
poison, and others which secrete that, which applied to, or inserted in our 
bodies, produces a deleterious effect, which is generally of a definite kind. 
Thus, the venom of the rattlesnake produces a disease of definite form ; 
cantharides another; certain fish are poisonous when eaten; wasps and 
bees instil a venom ; and the smallest visible gnat, as that which inhabits 
the forests of the middle latitudes, and that which is known under the name 
of sand fly on the shores of the Grulf of Mexico, inflames the skin ; while the 
juice of stramonium, the exhalations of the rhus toxicodendron, and the 
fungus which grows beneath its shade, excite peculiar diseases. It seems 
justifiable to ascribe, by analogy, to microscopic animals and plants, the 
same diversity of properties which we find in larger beings, differing from 
them, as we may presume, in nothing but size and complexity of organi- 
zation. We may suppose, then, that while many species of this minute 
creation are harmless, there are others, which can exert upon our systems a 
pernicious influence. This, moreover, is in accordance with what we know 
of gases, some of which, as nitrogen, are inert, while others are deleterious. 



INTERIOR VALLEY OF NORTH AMERICA. 39 

Under this head, moreover, we must not forget the fact, that nearly all the 
animals and plants which secrete a poisonous fluid, grow in the southern 
regions, and we may, analogically, suppose that the microscopic beings in 
those regions are more pernicious than those of higher latitudes. Now it is 
in the warmer portions of our Valley, that autumnal fever has its greatest 
prevalence. 

3. We know that water is essential to the support of those animal and 
vegetable forms which are matters of observation by the unassisted eye ; 
and many conclude, therefore, that it is equally necessary for the tribes 
which are invisible. Indeed, it is known of many, as the rotiferse, that if 
deprived of moisture, they seem to die, but may be revived many years 
afterward by the application of that fluid. Now we have seen that, in the 
western part of the Valley, where great aridity prevails, the Fever is almost 
unknown; while it prevails with greatest frequency and violence, other 
conditions being the same, where there is adequate humidity. 

4. A high temperature is favorable to the development of animal and 
vegetable life. In the southern parts of the Valley, animal forms, especially 
of the lower order, are greatly multiplied, and vegetation is luxuriant. If 
this be true of the visible, why may we not conclude that it is equally true 
of the invisible. Now, it is precisely in those regions, that the Fever, other 
circumstances being equal, displays its greatest prevalence and malignity. 
"When we look to the north, we find that, after reaching the parallel which 
has an isotheral curve of only sixty degrees Fahrenheit, the amount of visible 
organic life is much diminished, and continues rapidly to decrease ; we may 
therefore presume, that the same is true of microscopic plants and animals. 
But we have already seen, that where the summer temperature falls below 
sixty degrees Fahrenheit autumnal fever is unknown. 

5. In the visible organic world, we find animals subsisting on plants, or 
on other animals that have fed on vegetables. Again : the decomposing 
remains of one generation of plants, favors the growth of another; and thus 
the soil gradually acquires the ability to bring forth a more luxuriant crop. 
Organic matter is, then, the proper, though not sole nutriment of organized 
beings. Such being the law, we may presume that, cseter is paribus, where 
dead organic matter is most abundant, microscopic tribes will be most mul- 
tiplied. It is a familiar fact, that such matter abounds, through almost 
every stage of its decomposition in visible beings, which subsist upon it. 
Thus flesh has the larvas of the green and many other flies ; rotten wood its 
grubs; vinegar, as the result of decomposition, its eels — sometimes visible 
to the naked eye ; cheese its visible and invisible inhabitants ; and bread its 
mould, a cryptogamic plant. Finally, all vegetable infusions, when exposed 
to the air have their infusoria. It is impossible, then, to doubt, that 
myriads of microscopic beings swarm around, and enter the interstices of all 
dead organic matter; and thus we have reason for believing, that they 
prevail most where such matter is most abundant : and it is in the same 



40 THE PRINCIPAL DISEASES OF THE 

localities, other circumstances being equal, that we find the greatest 
prevalence of the Fever. 

6. By the vegeto-animalcular hypothesis, we can explain the concentrated 
prevalence of the Fever in certain places, as rationally as by the malarial 
hypothesis. Thus, its virulent reign at the head of Pensacola Bay, where 
there are extensive deposits of river alluvion, may be referred to the multi- 
plication of animalcules or germs, where they find abundance of nutriment; 
and in the case of the exposure of the face of a deep stratum of silt by 
the removal of a mill-dam on Cedar Creek ( Vol. II, p. 31), we have only to 
suppose, that they immediately began to multiply upon the denuded surface. 

7. It has often been observed, that the Fever has suddenly increased 
after rain ; and this might have arisen from the resuscitation of organic 
forms rendered torpid by previous drought. 

8. It may be, that cold produces a state of suspended animation in these 
as in many larger animals, and in numerous plants ; and that the first warm 
weather of spring revives and sets them to multiplying ; when they generate, 
what are called vernal intermittents (or at least, a part of such cases); the 
origin of which cannot be rationally ascribed to malaria developed at that 
time. 

9. Microscopic observation and analogy render it probable, that in the 
invisible, as well as the visible province of the organic kingdom, there are 
distinct species, which constitute, by their union, natural families or orders. 
We know that in each natural assemblage of the larger plants and animals, 
the species resemble each other in many internal qualities, as well as in their 
forms. Thus, an astringent principle pervades the various kinds of oak ; 
a resinous principle the linear evergreens ; an aromatic oil, the peppermint, 
and other didynamous herbs; a poisonous principle, the different species of 
rhus ; and that a narcotic principle pervades a large assemblage of plants. 
We know, also, that these various active principles in each group, are in 
general analogous, but not identical ; whether we examine them by their 
sensible properties, with chemical reagents, or observe their effects upon 
the living body. Now, may it not be, that two distinct species of the same 
natural order of microscopic beings may produce autumnal fever ? May 
not one be the cause of intermittents — the other of remittents ? may not 
both act on the system at the same time? and may we not thus explain 
diversities, which are inexplicable on the malarial hypothesis ? Every practi- 
cal physician knows, that while the juice of a variety of plants will produce 
the pathological condition called narcotism, the symptoms of that state, when 
induced by different agents, differ as widely from each other, as the symp- 
toms of the different forms of autumnal fever. 

10. In discussing the meteoric hypothesis, it was said, that the patho- 
logical effects of a certain condition of the principles of the atmosphere, are 
always immediate ; and it might have been remarked, when treating of the 
malarial hypothesis, that as far as we know, the effects of gases are likewise 



INTERIOR VALLEY OP NORTH AMERICA. 41 

immediate ; but we are certain that autumnal fever often begins many days, 
and even weeks or months, after an exposure to its remote cause. Now 
we know, as a general fact, that many animal poisons do not develop 
their effects, till after the lapse of a greater or less length of time. Thus, 
two weeks may elapse before small-pox will appear, after exposure ; and two 
years have passed away, before hydrophobia has followed on the bite of a 
mad dog. On this point, then, the vegeto-animalcular hypothesis, has an 
advantage over both the others. 

11. It has been already stated, that autumnal fever prevails very une- 
qually in different years; and that, in the same locality, it may, in one 
autumn, be malignant and epidemic, and in another, mild and sporadic. 
This can, perhaps, be better explained on the hypothesis we are now discuss- 
ing, than on either of the others ; for we know, that throughout the visible 
organic domain, reproduction is by no means uniform. A year of great 
abundance, may be followed by one unproductive, in the vegetable king- 
dom ; and in the animal, one summer and autumn will be infested by insects 
far beyond another. It has often happened, that musquitoes have been 
absent from the banks of the middle portion of the Ohio River, for a year, 
and in the next appeared in immense numbers. TVe have but to suppose 
insect forms of a parallel size, to live under corresponding laws, and the hy- 
pothesis now before us, offers an explanation of sickly and healthy seasons. 

12. It is well known that the long-continued cultivation of the soil, and 
the building of towns and cities, diminishes the prevalence of the Fever. 
Now this cultivation implies the drying up of a great deal of surface water; 
the burning up of the natural vegetation, and the gradual decomposition of 
that which has been mingled with the soil. Summer crops, as those of 
wheat and hay, are also removed, and not suffered like the natural herbage 
to accumulate on the surface ; and those of autumn are either removed, or 
in the course of the winter consumed, to prepare the fields for new planting. 
Thus the food of microscopic beings is destroyed, and their reproduction 
arrested. 

13. We are familiar with the fact that many persons never sicken with 
autumnal fever, while others around them will have repeated attacks. This 
is ascribed to difference of susceptibility, and of exposure to exciting causes. 
Such ascription is no doubt correct ; but the vegeto-animalcular hypothesis 
offers, from analogy, an additional explanation. It is well known that cer- 
tain visible insects prey on some individuals much more than others — seem 
to be attracted by one and repelled by another — and we have but to grant 
to the invisible the same tastes and instincts, to understand that some 
persons may always draw swarms around them, while others escape their 
depredations. 

14. People who inhabit houses built on the hills adjoining valleys are said 
to suffer more than those who reside below. Now every breeze may waft and 
lodge in such habitations the microscopic beings which multiply in the rich 
and humid valley-soil. It has also been observed, that a grove of forest 



42 THE PRINCIPAL DISEASES OP THE 

trees between an inhabited house, and what is called a sickly spot, gives com- 
parative immunity from the Fever; and may not the leaves of such trees as 
successfully arrest animalcules, or vegetable germs, as they can absorb a gas 
not designed for their nourishment? 

From what has been said, it appears obviously, I think, that the etiological 
history of autumnal fever, can be more successfully explained by the vegeto- 
animalcular hypothesis, than the malarial. But both, in the present state of 
our knowledge, must stand as mere hypotheses. Neither can claim the rank 
of a theory ; nor will it be entitled to the confidence of the profession until 
many additional facts are brought to its support.* 

IV. Value of the Discovery of the Efficient Cause of Autumnal 
Fever. — I cannot, a priori, attach much practical importance to a discovery 
of the efficient cause of autumnal fever ; and have devoted several pages to 
its discussion, from deference to my brethren, much more than from my own 
conviction, of the value of the discovery to which so many minds are directed. 
Did we know the particular meteoric condition, the gas, or the organized 
microscopic species which produces the Fever, we should not probably be 
able to defend ourselves against it, by any precautions, but those which 
experience has already established ; nor should we be, able to destroy the 
efficient cause without annihilating the conditions under which it is generated. 
Those conditions are already well known. The individual exposed to them 
is liable to an attack — he who keeps away remains exempt. The people of 
the country escape the vesicular eruption produced by the rhns toxicodendron 
or the rhus vernix, by keeping beyond the sphere of exhalation. They 
know nothing of the nature of the poisonous emanation, and yet their means 
of protection are as perfect, as those of the chemist would be, who might 
analyze the poison and give it an appropriate name. Nor is it probable 
that the discovery of the efficient cause would throw any light upon the 
treatment. It was not a knowledge of its cause that taught us the cold 
treatment of small-pox; — we know the cause of hydrophobia and yet 
cannot cure it; — we do not know the cause of goitre, but have discovered 
that iodine is an efficient remedy. 

Ignorant, however, as we are of any definite efficient cause for autumnal 
fever, I am a full believer in its existence, and shall speak of it as a specific 
agent, known only by its effects on the living body. These effects constitute 
the disease we have been studying in its etiology ; and are now to contem- 
plate in its symptomatology, pathology, and therapeutics. In proceeding to 
do this, the first inquiry naturally is, into the manner in which the assumed 
agent makes its impress on the system. In doing this, I wish it understood 
that if I should, at any time, use the word malaria, it is merely to designate 
the remote cause, ivhatever it may be. 

* When this article was about to be sent to the press, a friend handed me Professor Mitchell's Lectures 
on the " Cryptogamous origin of Malarious and Epidemic Fevers, " which I had not before seen. The 
array of facts made by the learned author, seems almost irresistible; and from his distinguished repu- 
tation, it will no doubt, lead many others into new courses of observation and experiment. 



INTERIOR VALLEY OF NORTH AMERICA. 43 



CHAPTER III. 

MODE OF ACTION AND FIRST EFFECTS OF THE REMOTE CAUSE OF 
AUTUMNAL FEVER. 



SECTION I. 
APPLICATION OF THE POISON. 

Assuming the existence of a poison concealed in the atmosphere, we are 
led to inquire on what surfaces it makes its primary impression. 

I. Action on the Skin. — Several known gases act with such energy on 
the cutaneous surface, that when they are applied, for some time, they pro- 
duce decided effects.* But can this be affirmed of the cause of autumnal 
fever ? Does it modify the vital properties, and pervert the functions of the 
skin; and, through sympathy, the organism generally? Does it penetrate 
that integument and mingle with the blood ? There are facts which seem to 
favor an affirmative answer, to at least one of these questions. First. Ex- 
posure of the surface of the body to the night air, in early autumn, is often 
followed by an attack of the Fever. Second. The functions of the skin, 
both perspiratory and calorific, are signally impaired in the forming stages of 
the Fever. In opposition to the first of these facts, it is well known that a 
hearty meal, a debauch with wine or whiskey, the action of a hot sun, or the 
violent operation of a cathartic, when the Fever is epidemic, may invite an 
attack; and the exposure of the body at night, may like them, be only an 
exciting cause. In opposition to the second I may say, that the other 
functions of the body are impaired, as early and extensively, as those of the 
skin. Proof is wanting, then, that the remote cause acts upon or penetrates 
the skin, to the production of this fever, though the opposite cannot, in the 
present state of our knowledge, be established. 

II. Action on the Stomach and Bowels. — The remote cause has 
been supposed to exert its primary influence on the gastro-intestinal mucous 
membrane, or to enter the circulation through that surface. The facts in 
support of this opinion are : First. The early derangement of the functions 
of the stomach, liver, and bowels, evinced by loss of appetite, nausea, 
increased or suppressed secretion of bile, and constipation, or diarrhoea. 
Second. The actual development, in many cases, of gastro-enteritis. Third. 
The alleged necessity of admitting the latter condition, as requisite to the 
production of the Fever. 

But these facts are inconclusive, and the objections to the hypothesis many. 
In the first place, as I have said of the lesion of the functions of the skin, 
those of the digestive organs have no priority over lesions of other functions. 

* Edwards on Physical Agents. Muller's Physiology. Christison on Poisons. 



44 THE PRINCIPAL DISEASES OF THE 

Muscular languor, impaired perspiration, diminished heat, heaviness of the 
head, reduced activity of the mind, and pain in the back, or several of these 
symptoms, are as early in their appearance as the disorders of the digestive 
organs — sometimes earlier; for every physician has met with cases, in the 
forming stage of the Fever, in which he found it necessary to prohibit the 
patient from eating. In the second place, both the symptoms and the 
required treatment of numerous cases, show that gastro-enteritis is not 
present. Indeed, splenitis is oftener present than mucous inflammation, and 
hepatitis is by no means uncommon ; but the cause of the Fever cannot 
reach either of those organs without penetrating others. And if they can 
become inflamed, without being directly acted on by the poison, the existence 
of gastro-enteritis is no evidence, that it has made its first impression on the 
stomach and duodenum. In the third place, the influence of a hearty meal 
(in cases in which the appetite has not been destroyed), in exciting the 
Fever, and even developing gastritis, does not prove that the cause had 
acted on the stomach ; for if the organism at large had felt its influence 
through whatever channel, and the stomach had then been irritated by a 
meal, which it could not digest, the sympathetic relations between it and 
the whole system might, at once, arouse inflammation in the former, and 
fever in the latter. In addition to these objections it may, in the fourth 
place, be asked, how an agent so subtle, as to have hitherto escaped detection, 
can find its way in the stomach, in such quantities as to prove injurious, 
either by its action on the mucous membrane or its passage into the blood ? 
It could only reach there, by being mingled with our food and water ; which, 
for aught we know to the contrary, may be the case, but I know not of a 
single fact in support of this opinion. 

III. Action on the Lungs. — If the cause of autumnal fever be mingled 
with the atmosphere it must be received into the lungs ; for universal expe- 
rience shows that it is not one of those gases which provoke a closure of the 
glottis, and thereby occasion its own occlusion. Does it then, make its 
primary morbific impression on the pulmonary mucous membrane? In sup- 
port of the affirmative of this question, it may be stated, First. That the 
area of that membrane is sufficient to admit of an extensive contact of the 
aerial poison. Second. That its susceptibility to the action of gases is far 
greater than that of the skin or gastro-enteric membrane ; and, therefore, 
as compared with them, it is more likely to be the surface on which aeriform 
poisons make their primary impression. It may be objected to this hypo- 
thesis, however, that the function of respiration is less impaired in the early 
stages of this fever, than most of the other great functions, and that 
bronchitis is but seldom developed. The former is entitled to consideration, 
but the latter is not, inasmuch as all morbific agents do not necessarily excite 
inflammation in the parts upon which they act ; and, it has not yet been 
shown, that the cause of autumnal fever is one of those which do. Never- 
theless, I cannot regard the opinion that autumnal fever has a pulmonary 



INTERIOR VALLEY OF NORTH AMERICA. 45 

origin, as anything more than an hypothesis. As nitrogen, oxygen, and some 
other gases have been found to enter the circulation through the skin, it is 
possible that the cause of this fever may be introduced in the same way. 
Should it be introduced into the stomach and bowels, it might thence enter 
the blood, as there is reason to believe that certain gases do.* But passing 
by these surfaces, as altogether subordinate we may turn to the pulmonary, 
as that through which most gases pass into the circulation. Of the reality 
of this absorption, no physiologist can entertain a doubt. In fact, it seems 
to be almost as much a function of the pulmonary membrane, to absorb cer- 
tain gases and odors, as it is of the gastro-enteric to absorb liquids. Thus 
Dr. Edwardsf has demonstrated the absorption of oxygen, azote, hydrogen, 
and aqueous vapor, by the lungs. Others have confirmed his observations, and 
rendered the absorption of other gases highly probable ; finally, all the world 
is familiar with the fact, that a great variety of odorous exhalations are like- 
wise absorbed — often rapidly and copiously. Such being the penetrability 
of the pulmonary membrane, there is no anatomical or physiological objec- 
tion to the theory of the passage of the efficient cause of autumnal fever 
through that tissue into the blood ; still, this does not prove that it is 
absorbed — only that it may be. But there are no proofs of the fact ? I 
know of none, which do more than render it probable. First. We have 
seen, that there is no evidence, that the morbific impression of this cause is 
made on the skin or mucous membranes with which it is in contact ; and 
yet its action on the system is a reality, hence we may conclude that it pene- 
trates through some surface to the blood. Second. As various gases, vapors, 
and odors, penetrate the thin parietes of the vessels of the pulmonary mem- 
brane, we may conclude from analogy, that the efficient cause of this fever 
may do the same. Third. Dr. Stevens has shown that, in the endemic fevers 
of the West Indies, the blood suffers deterioration before the phenomena of 
fever have manifested themselves in the functions of the solids. Fourth. The 
universality of functional lesion, and, in most cases, its equality among the 
different organs, in other words, the involvement of the constitution, would 
seem to indicate, that the remote cause has acted throughout the whole 
organism at the same time. Fifth. A prominent and most dangerous condition 
in autumnal fever, is the impaired state of the calorific function, found in its 
highest degree in algid intermittents. As the blood evidently plays an im- 
portant part in this function, may we not conclude that in these remarkable 
cases, it has undergone a change in its composition or constitution, which 
unfits it for the development of caloric ! Whatever may be the agency of 
the nervous system in this function, it is undeniable that the blood is imme- 
diately and deeply concerned; and highly probable that its agency is 
according to chemical principles. Should it then be altered in its con- 
stituents, or their mode of union, an alteration in its calorific agency would 
be inevitable. It must not be forgotten, however, that in the stage of febrile 
reaction there is increased heat. Nevertheless, there are cases in which, 

* Christison, page 698. f Edwards on Phys. Agents. 



46 THE PRINCIPAL DISEASES OF THE 

during that stage, the extremities continue cold. Sixth. An argument in 
favor of this hypothesis may, perhaps be found in the well-known fact that 
a suppression of perspiration by lodging in the open air, tends to excite the 
disease, and that a copious perspiration, effected by art in the forming stages, 
often arrests it. While the function of perspiration continues active, the poi- 
son absorbed by the lungs may pass off through the skin ; but being arrested 
in that exit, may, by its accumulation, prove mischievous, and when it has 
already begun to do harm a copious sweat may relieve the system of such 
an amount that fever may be averted. Seventh. Nearly connected with 
these views, and tending to the same point, is the fact, that as long as the 
nights continue warm, the disease does not become epidemic; but as soon 
as they become so cool as to check the functions of the skin, by diminishing 
its capillary circulation, and surrounding it with a damp atmosphere, from 
the liberation, by the reduction of temperature, of a portion of vapor which 
was insensible at a higher degree of atmospheric heat, the Fever assumes an 
epidemic character. 



SECTION II. 



MODE OF ACTION. 



Supposing the agent which produces the Fever introduced into the blood 
through the lungs, what may be its mode of action ? Experiments by 
various physiologists and chemists* have shown, that in reference to their 
effects upon the living body when inspired, the known gases may be divided 
into the inert, the irritant, and the narcotic. Of the first class, are azote 
and hydrogen, which prove injurious entirely or chiefly by excluding atmo- 
spheric air. To the second class belong nitric oxide gas, nitrous acid vapor, 
muriatic acid gas, chlorine, sulphurous acid, and ammonia ; all of which 
irritate in a sensible manner, or inflame the aerial passages, and some of 
which, in a very dilute state, if inhaled for a considerable time, prove 
narcotic. In the third group are comprehended sulphuretted hydrogen, 
carburetted hydrogen, carbonic acid, carbonic oxide, nitrous oxide, cyanogen, 
oxygen, ether, and chloroform, in which the narcotic greatly predominates 
over the irritating property. 

Judging by its first effects, as found in the early stages of autumnal 
fever, to which of these classes should we refer the cause of that fever ? 
Not to the inert, which destroy life simply by excluding the atmosphere, for 
it causes no such exclusion ; not to the exclusively irritant, for, as we have 
seen, they inflame the respiratory membrane; not to the entirely narcotic, 
for somnolency is not a prominent symptom of the early stage of that fever. 
Relying on its effects, to guide us in an estimate of its character, we may 

* Christison, p. 689. 



INTERIOR VALLEY OF NORTH AMERICA. 47 

say, that the efficient cause of this fever is a peculiar poison, of a sedative 
and irritating quality, somewhat like the narcotico-irritating gases, or cer- 
tain solid and fluid bodies, which, in large doses, destroy life suddenly, by 
reducing power, and in smaller portions, weaken while they pervert the 
functions. Assuming this, let us inquire concerning its action, first on the 
blood, and secondly on the solids. 

1. In reference to the blood, we can only regard this agent as something 
absorbed and mingled with it : a foreign substance united with the water, 
in which the saline and animal ingredients are dissolved or suspended. Of 
its effects on these, or the manner in which they are produced, we are pro- 
foundly ignorant. Still, as the introduction of a foreign ingredient, into a 
fluid so compounded, cannot be made without disturbing the equilibrium of 
its affinities, and changing its isometric character, we are bound to admit a 
deteriorated condition of that fluid, if the absorption be a reality. From 
the physiological relations between the blood and the containing solids, from 
the moment this condition is established, the action of the former upon the 
latter, must be different from what it is in health; and the change, however 
brought about, is to disease. The influence of such a blood on the nervous 
system, and all the organs of secretion, not less than on the heart and 
vessels, being different from what that influence is, when the blood is in a 
normal condition, the functions performed by those great structures, are 
necessarily altered ; and here may be the origin, in part, of the first symp- 
toms of the fevers we are considering. 

2. But the agent which has passed into the .blood, may retain its inte- 
grity, and produce effects peculiar to itself, by acting on the parts with 
which it is brought in contact. These are the entire internal surface of 
the arteries, veins, and heart. That this surface is of vast extent, we are 
taught by anatomy ; and that its arterial portion, at least, is exquisitely 
alive to the impress of foreign matter, has been equally demonstrated by 
experimental physiology. That the heart is endowed with a high degree of 
irritability, was shown long since by Haller; and that it possesses nerves, 
has been proved by Scarpa. That the smaller arteries and capillaries are 
likewise endowed with, nerves, has been demonstrated by Lucre j* that they 
are the seats of the liveliest sensibility, is obvious to every observer ', and 
that the nervous system exercises over their circulatory and secretory func- 
tions, a constant and decided influence, has been established by the ex- 
periments of Sir Wilson Philip and others ; if, indeed, it has not forced 
itself upon the attention of every observing physician, in the modifications 
of secretion and calorification, which result from varying states of the inner- 
vation. Such is the surface with which the absorbed and undecomposed 
poison is brought in contact. A surface not protected, like the skin, with 
cuticle ; not limited to a group of organs, and defended with mucus, like 
the pulmonary or gastro-intestinal membrane ; but undefended; more exten- 

* Beclard's Anat. Gen. 



48 THE PRINCIPAL DISEASES OF THE 

sive thaD the whole of those taken together j found in every organ of the 
body, and most developed in those which perform the most vital functions. 

3. If we concede to the cause of autumnal fever, a peculiar narcotico- 
irritating quality, its necessary effects, in such a mode of application, will be 
those which constitute the first stage of that fever — reduction of vital 
energy, obtuseness of sensibility, suspended or prevented secretion, and 
diminished calorification j and from an equal necessity, they will be felt in 
all parts of the body, because the agent which produces them travels with 
the circulation. We may assure ourselves, that its first effects will not be 
increase, but depression of excitement, by referring to the constitutional 
influence of foreign matters, liquid or gaseous, when introduced into one of 
the serous membranes (as a peritoneum, for example), which are always 
those of depression as well as irritation. If we suppose such matters to be 
simultaneously introduced into all the serous sacs of the body, we should 
expect immediate reduction of the vital powers, and early death; though we 
can conceive of the quantity being so small, that the system would react, 
and fever and inflammation ensue. I can see no logical objection to this 
analogy. 

4. If we combine these effects, with those supposed to be produced by 
the altered state of the blood, and with the whole, those which must neces- 
sarily and immediately result to that fluid, from the reactive influence of 
the diseased solids, we have before us the pathological state which consti- 
tutes the first effect of the remote cause, and the first stage of the Fever; 
a stage which the hypothesis (for it cannot be regarded as an established 
theory) seems adequately to explain ; and, by explaining, to commend 
itself to our consideration and confidence. Having now accomplished the 
object proposed in this chapter, let us proceed to inquire into the develop- 
ment of the Fever. 



CHAPTER IV. 

VARIETIES AND DEVELOPMENT OF AUTUMNAL FEVER. 



SECTION I. 
VARIETIES. 

The first effects, or morbid impressions, produced by the remote cause of 
our autumnal fever, are so nearly the same, whatever may be the subsequent 
type, that in many, indeed, in most cases, that type cannot be seen through 
them. In their incipient stages, the different forms of this fever are not, in 
general, to be distinguished ; but as they advance, a difference in type mani- 



INTERIOR VALLEY OF NORTH AMERICA. 49 

fests itself; and as a first division we separate them into intermittents and 
remittents. 

I. Intermittents. — The intermittents of our Valley, are generally quo- 
tidian or tertian, oftener, I think, the latter than the former. Now and then 
a double tertian, challenges the acumen of the physician, in distinguishing 
it by the hours of recurrence, or the violence of the alternate paroxysms, 
from a quotidian. An original quartan I have never seen; but quotidians 
occasionally assume that character. Whatever may be its type, as to perio- 
dicity, our intermittent fever presents several varieties or modifications, 
founded on pathological causes, or conditions. 

1. It may be mild, simple, accompanied by a perfect intermission; and if 
not combated by art, may, still, not prove dangerous; though it may con- 
tinue to the impairment of the constitution, which is true of both quotidians 
and tertians. 

2. It may exhibit a deep or protracted cold stage, with imperfect reaction ; 
and in the first, second, or some subsequent paroxysm, prove fatal; and this 
also may be true of that which recurs daily, or every other day. These are 
the malignant or congestive cases; the former epithet for which, should be 
preferred, as not involving a hypothesis, or directing the attention of the 
physician upon a single pathological condition. 

3. It may assume an inflammatory character, with a diminished cold, and 
a prolonged hot stage, running at length into a remitting type. 

II. Remittents. — 1. These are generally characterized, in their varie- 
ties, by the same language as intermittents. Many of them are simple, and 
without much active treatment, after running a course of eight or ten days, 
terminate in health, or in simple intermittents. This is oftener the case in 
the middle than the southern latitudes. 

2. Other cases, from the beginning, or in their progress, display a de- 
cidedly phlogistic character, with signs of inflammation in some organ, and 
a tendency to a continued type. 

3. In various localities, especially to the south, a form of this fever has 
received the name of congestive or malignant. It appears to differ from the 
malignant intermittent in the absence of a regular apyrexia; from the 
simple remittent, in the mixed up, ataxic, and threatening character of its 
symptoms; and from the inflammatory remittent, in the signs of great pros- 
tration, and the absence of an open inflammatory aspect. Cases of this kind 
are much rarer than cases of malignant intermittent. 

4. The first two varieties of remittent fever often terminate in intermit- 
tent. That the last does not so frequently, may be ascribed to the amount 
and activity of treatment which is necessary to the recovery of the patient. 

5. Intermittents left to themselves, rarely cease till they have continued 
for a long and indefinite time. But they may be made to cease at any 
period of their duration. It is not necessary to defer the means of their 
arrest, till a number of paroxysms have returned, as some physicians have 

vol. n. 4 



50 THE PRINCIPAL DISEASES OF THE 

imagined. Remittents of a simple character, on the contrary, as I have 
already intimated, will cease of themselves ; and cannot so certainly be cut 
short in their early stages, as intermittents. I have not, however, seen, or 
been able to collect, evidence of critical days in this fever. Its duration, 
very commonly, is a week or more, rarely a fortnight, except when compli- 
cated with manifest inflammation of some organ, or when they manifest a 
typhous character. 

6. Why is it, that the cause, whose effects we are considering, produces 
fevers of a periodical type ? I know not that any answer can be given to 
this question. It is the specific effect of the remote cause. It results from 
the relations between that agent and the living system on which it acts. 
When we can tell how the variolous poison produces cutaneous pustules, the 
morbillous a rash, and mercury a salivation, we may be able to tell, why 
autumnal fever is essentially periodical, and not before. 

7. Nor is it plain, why the same remote cause will occasion an intermit- 
tent in one, and a remittent in another ; why one shall have a quotidian, 
another a double tertian, and another a tertian ; or, why several shall have 
simple, and one a malignant intermittent, when all inhabit the same locality. 
Perhaps, however, varieties of constitution and exciting causes, with unknown 
modifications of the remote cause, may be looked to, for a solution of this 
difficult problem. On the last, my late colleague, the learned Professor 
Caldwell,* has laid a degree of stress, which might arrest our attention, if 
the cause of these fevers, in any of their varieties, had been discovered ; 
and, if they did not all prevail at the same time, in the same places. 

It might be presumed that the statistics of these varieties of fevers would 
throw light on this subject., The table, Vol. II p. 20, presents the relative 
portions of intermittents and remittents at twenty-six military posts. If 
these be divided into southern, middle, and northern groups, we find that for 
the southern, the remittents make twenty-one per cent. ; the middle fourteen 
per cent., and the northern twenty per cent. Thus, it does not appear, that 
temperature exerts an influence on the relative number of intermittent and 
remittent cases. But may not humidity ? Let us consult the table on this 
point. Six posts around the Gulf of Mexico, give for remittents twenty per 
cent. ; and seven on the Lake shore, give thirteen per cent. ; while eight 
along, or west of the Mississippi, where the atmosphere is dryest, give only 
ten per cent. From these numbers it would appear, that humidity increases 
the proportion of remittents. But can we adopt this conclusion ? I think 
not; for ordinary observation has shown that remittents are even more 
common than intermittents, on dry ridges, while in deep valleys and other 
humid localities, intermittents prevail. It must be, then, that while the 
army reports may be correct as to the aggregate, they are not to be relied 
on, for the relative number of intermitting and remitting cases. The mean 
of the twenty-six posts is about eighteen per cent, of remittent fever ; but 

* Prize Dissertation on Malaria. 



INTERIOR VALLEY OF NORTH AMERICA. 51 

from several yearly reports, kindly communicated to me by Dr. Silas Ames, 
of Montgomery, on the high bluffs of Alabama River, in N. L. 32°, the pro- 
portion of remittent cases is about forty-three per cent, of the whole, occur- 
ring in his practice. Since these statements were prepared for the press, 
I have met with a transcript of the records of the Charity Hospital, New 
Orleans, for seven years, by Dr. Fenner,* which presents the proportion of 
remittents, at but ten per cent, of the whole ! Such discrepancies show how 
little reliance can be placed on the attempted classification of autumnal fever 
into intermittent and remittent. 



SECTION II. 

DEVELOPMENT AND PATHOLOGICAL CHARACTER. 

Having studied the modus agendi of the remote cause of autumnal fever, 
and enumerated the varieties of type under which it appears, we are pre- 
pared to inquire how they are developed. In doing this, we shall regard 
them as constituting, essentially, one pathological state \ and in studying its 
modifications, we shall become acquainted with the causes of some of the 
modifications presented in its symptoms, and the varieties of treatment which 
they render necessary. 

I. Of the Forming or Cold Stage. — This commences with the initial 
morbid impression, which we have already considered ; and, in simple or 
inflammatory cases, terminates with the access of the hot stage, to be repro- 
duced, on the next or some subsequent day. This paroxysmal character, 
not less than the symptoms which characterize this stage, shows, that the 
function of innervation is deeply involved and embarrassed. We may, in 
fact, admit, that it is the first affected. The state of the circulation, equally 
indicates that the forces which maintain it, are reduced. The heart is en- 
feebled, and the co-operative action of the vessels, however it may be exerted, 
has failed in a corresponding degree. Hence the blood no longer flows in 
normal quantities, through the more exterior or peripheral portions of the 
body, but retreats to, or rather remains in, the organs of the cranium, chest, 
abdomen, and pelvis. Under this condition of the two great functions of 
innervation and circulation, the secretions become still further impaired, 
than at the beginning. The perspiration is suspended ; and, in many cases, 
the exhalation from the lungs is reduced, because the respiration is brought 
down ; and the blood seems not to favor the extrication of what is exhaled 
in health. The urinary secretion is, also, reduced in quantity ; and the 
bowels are not in the soluble condition which indicates a due secretion of the 
liquor intestinalis. But of all the secretions, that of the liver is most af- 
fected, or at least the signs of biliary derangement are greatest. A yellow 

* N. 0. Med. and Surg. Jour., July, 1S4S. 



52 THE PRINCIPAL DISEASES OF THE 

tinge of the urine, skin, and eyes, is often among the earliest of the morbid 
appearances. In many cases, especially the more simple, the liver pours 
out torrents of bile ; which, in part, ascend through the pylorus, raise a 
bitter taste in the mouth, and impart yellowness to the otherwise white fur 
upon the tongue. In other cases, the secretion of bile is nearly, and, in 
many of the more violent cases, entirely suspended j or what is thrown out 
by the gland is of a vitiated quality. It was this disturbed condition of 
the hepatic function, that procured for autumnal fever the name of bilious, 
and has so often suggested its treatment. How are we to account for the 
constancy and prominence of these symptoms in this form of fever ? Shall 
we say, that a plethoric state of the portal viscera is their proximate cause ? 
In many other fevers, we have an equal concentration of blood, in the inter- 
nal parts, without an equal increase or perversion of the hepatic functions ; 
nevertheless, we may admit turgescence as one of the pathological causes of 
increased or even suspended secretion of bile ; according to the degree of 
engorgement and the reduction of energy and activity in the solids. But 
something must be sought beyond this. We may admit, that from the sym- 
pathy between the skin and liver,* the great heat of the preceding summer 
has raised the liver into high and deranged functional action. We may, 
also, conjecture, that the action of the remote cause, wherever it may impress 
itself first, is, from its nature, determined upon the liver ; as the virus which 
produces scarlatina or erysipelas, determines its action upon the skin, or the 
mucous membranes of the throat. We may assume, that if the remote cause 
be received into the blood, the constitution — vis conservatrix — makes an 
effort to convey it out of the system, through the liver, as phosphorus passes 
out in the state of phosphorous acid from the lungs, when injected into a 
vein ;*f" sulphur through the skin, and various saline substances, through the 
kidneys. In all these cases, the foreign matter excites the organ upon which 
it directs itself or is directed, into increased secretory action ; and in like 
manner the cause of the Fever, in circulating with the blood, may be concen- 
trated on the liver, and promote the secretion of bile. Finally, we may per- 
haps admit as a possibility, that this foreign material contributes to the de- 
velopment in the blood, of the elements of the bile; which it is the function 
of the liver to combine and excrete. But, casting aside every attempted ex- 
planation, we must receive, as an established fact, that, even in the first stage 
of every variety of autumnal fever, the biliary function is signally deranged. 
Another equally characteristic feature of the Fever, is the derangement of 
the calorific function. This extends not only to the actual heat of the patient, 
but to the sense which takes cognizance of temperature. The calorific 
function, in many cases, seems, in the more external parts of the body, to be 
almost annihilated. Potential stimulants will not re-excite it; and the ex- 
ternal application of heat, is actually less efficient in warming the limbs of 
the patient, than in warming an equal bulk of dead and dry matter ; because 

* Johnson on Tropical Diseases. t Nysten, Die. de Sciences Medicales. 



INTERIOR VALLEY OF NORTH AMERICA. 53 

the exhalation that is constantly going on from the moist tissues, which seem 
to be brought into a condition which favors the escape of vapor, cools them. 
In many of these cases, the patient does not shiver, nor complain of cold, 
because the functions of his nervous system are too deeply smitten, to admit 
of their action on the muscles, or of his taking cognizance of the loss of 
caloric. In others, of less violence, the muscles are affected, and he shakes, 
complaining at the same time of the sensation of coldness. Finally, I have 
seen cases, in which these symptoms were present, while the heat of the 
surface was not below, or was even above the standard of health. Such 
anomalies show, that both the calefacient function, and the sensibility to 
caloric, are in a disordered condition. It would perhaps, be in vain to inquire, 
why this function is so pre-eminently affected in this fever ; especially, in 
many of its intermittent forms. The fact, like that of periodicity, would 
seem, in the present state of our knowledge, to be ultimate. We must refer 
it to the remote cause, and await its explanation in the progress of the 
science. 

Let us now turn our attention to the dangers and the causes of death in 
this stage of the disease. 

As already intimated, the cases in which a sense of coldness, with a rigor 
or a shake, is most developed are, in general, least dangerous. The very 
existence of the feeling and the muscular contraction, shows that the vital 
properties have been less scathed, than in cases in which those phenomena 
do not appear. Reaction soon manifests itself in such cases, and a stage of 
open, perhaps, violent excitement follows, to be succeeded either by a remis- 
sion or intermission, and then to be renewed. But in more dangerous cases, a 
different series of events is encountered. 

1. The vital powers may be so reduced that the patient will die, as indi- 
viduals die under the influence of prussic acid, or some other poison of a 
like kind. His susceptibility to the various sustainers of life is annihilated, 
and he sinks. Or, if according to the laws of relation between this aerial 
poison and the living system, a reaction take place, it is feeble and partial, 
and he perishes in the access of the next paroxysm. 

2. During the time that the forces which maintain the circulation are thus 
depressed, the blood may stagnate in the brain, or accumulate in the lungs, 
the heart, or the portal circle, in such quantities as to suspend the action 
of some of these great organs, and by its apoplexy, occasion the death of 
the whole. 

3. The blood itself, under the combined influence of an absorbed poison, 
the retained elements of the excretions, defective aeration, and the reactive 
influence of the morbid solids, may become unfit for the support of the great 
functions which depend upon it, and death be the necessary consequence. 

But these various pathological conditions, are not to be regarded as having 
a separate existence, for they are combined, and although one of them may 
predominate in one case, and some others in another, according to idiosyn- 



54 THE PRINCIPAL DISEASES OF THE 

crasies, predispositions, and the influence of accidental causes, they may all, 
in certain cases, contribute to the same fatal termination. 

II. Or the Hot Stage, or Stage of Excessive Excitement. — Natu- 
rally, that is according to the laws of relation between the remote cause and 
the living system, if the patient should not die, in the stage which has just 
been described, it is succeeded by that now under consideration, of which it 
is the pathological cause. The morbid action has taken a turn — the vital 
forces have risen from their depression, and excitement is reproduced ; but 
it is morbid. To what cause are we to ascribe this change ? 

1. It is a physiological law, that after depression there shall be elevation. 
From mere lapse of time, if not too strongly depressed, the organs recover 
their vigor, and begin to react. Various functions are restored ; but they 
are morbid, in proportion as the cause which depressed them was foreign in its 
nature from the agents which maintain life. To this tendency — this spon- 
taneous revival of irritability and sensibility — we may ascribe, in part, as 
least, the revival of excitement, and the production of the hot stage. If 
the constitution be vigorous, this revival is more likely to take place — if 
previously feeble, it may be sunk below the point of spontaneous reaction. 

2. When the blood is not too much vitiated, its centripetal accumulation 
may provoke the heart into reaction. 

3. We may, perhaps, admit, with Sir Wilson Philip, that the retained 
sanguineous excretions may, sometimes irritate the heart into reaction ; but 
this would probably only happen in the milder cases, in which that fluid had 
not become deeply altered. 

4. Should the vital properties of any internal organ have suffered les3 
than the rest, the hyperemia into which it is thrown, may at an early period 
establish inflammation in it, the very commencement of which would tend to 
raise the excitement of the system. 

5. Lastly, the external and internal stimulations, to which we subject our 
patients, contribute to the same result. 

But in whatever way it is brought about, when death does not happen in 
the stage of depression, high excitement ensues, and other phenomena, in- 
dicating new pathological conditions, offer themselves to our notice. 

1. The blunted sensibilities of the patient become morbidly acute — pain 
occurs in parts not previously affected, or becomes sharp where before it was 
dull. 

2. The heart, in most cases, acts with unwonted force, and the blood is 
thrown toward the periphery of the body ) but circulates with a rapidity which 
brings it speedily back upon the viscera. 

3. The calorific function is not only restored, but becomes excessive, and 
the intolerance of heat is augmented. 

4. The liver acts with uncommon energy, and the secretion and excretion 
of bile are correspondingly great ; at the same time the bilious hue may become 



INTERIOR VALLEY OP NORTH AMERICA. 55 

deeper than before, indicating either return of bile into the blood from the 
liver, or extraordinary development of its elements in that fluid. 

5. After the lapse of a few hours, in the interrnittents, and of a longer 
portion of a day, in the remittent form, this excitement abates, and an inter- 
mission or remission is declared by the tranquillity of the patient, the abate- 
ment of force and frequency of his pulse, and the occurrence of more or less 
perspiration. 

6. It may happen, however, that when the stage of excitement comes on, 
some organ or organs, will remain in a state of hyperemia, and pass into 
inflammation. These are, generally, the viscera of the abdomen, chiefly the 
spleen, liver, and gastro-enteric mucous membrane. 

a. Splenitis is so common an accident in our autumnal fever, especially our 
inflammatory interrnittents, as to suggest that we can nowhere look for the 
true anatomical character of that fever more successfully than in the spleen. 
Why it should be so great a sufferer cannot, perhaps, be told, except that it 
becomes greatly engorged in the forming stage of the Fever. 

h. Next to the spleen, or equally with it, the liver is liable to fall into in- 
flammation upon the access of the hot stage j but this is more especially the 
case in the remittent type. 

c. The mucous membrane of the stomach and duodenum, with that of the 
common gall duct, are liable to pass into the same condition. 

Thus, all the subdiaphragmatic viscera, except the pancreas, are subject to 
inflammation in this fever. Sometimes, however, from idiosyncrasy, or the 
co-operative action of certain causes, inflammation arises in other parts. Thus 
an inflammation of the brain or its envelopes may happen ; and when the Fever, 
makes its attack, late in autumn, the combined action of vicissitudes of 
temperature and that of the specific cause, developed at an earlier period, 
may determine the inflammation upon the lungs or pleura. Wherever the 
inflammation may be seated, it complicates the case, and creates a new kind 
of danger. Although it may abate with the subsidence of the hot stage, it 
does not cease. The affected organ shows signs of suffering during the 
apyrexia, which it renders imperfect. The suceeding exacerbation may be 
prolonged by it, and an intermittent may thus be converted into a remittent ; 
while the latter not unfrequently, as already said, passes nearly into a con- 
tinued type, from the same pathological cause. But the most dreaded com- 
bination of this kind, which we meet with in the Valley, is that in which an 
inflammation of an organ is associated with such depression of the general 
forces of the system, that but a feeble reaction occurs. That this is a 
reality, both the symptoms and post-mortem appearances have shown. 
Such inflammations are never very acute. The organ is greatly engorged ', 
but the actions which constitute inflammation are feeble ; and after death, 
appearances which indicate congestion or passive hyperemia, are more con- 
spicuous than the vestiges of true inflammation. Between these cases and mere 
congestion of the organ, there is often but a shade of anatomical difference. 



56 THE PRINCIPAL DISEASES OF THE 

Having considered the origin and mode of invasion of the remote cause of 
autumnal fever, the nature of the morbid impression, and the consequences 
of that impression in the production of the cold and hot stages of the 
various forms, we have continued our generalization to its legitimate limits, 
and must now, by analysis, resolve what we have treated as one pathologi- 
cal state, into several; that the peculiarities of each may be presented. 
In doing this, we shall recur to the varieties enumerated in the preceding 
chapter. 



CHAPTER V. 

INTERMITTENT FEVER— SIMPLE AND INFLAMMATORY. 

Much time has been devoted, by the nosologists, to the division of in- 
termittents according to their periodicity. Regarding such classifications 
as of little practical value, I shall pass them by, and adopt that which seems 
best fitted to suggest the variety of treatment, which in this country they 
require. This classification, as already made, is into simple, inflamma- 
tory, and malignant; which terms do not represent three different diseases, 
but grades or modifications of one, which often presents intermediate shades, 
that obscure the lines of distinction. I shall commence with the first. 



SECTION I, 

SIMPLE INTERMITTENTS — HISTORY AND PATHOLOGY. 

I. History. — It is quite unnecessary to give an elementary description 
of this variety. From south to north, its symptoms, progress, required 
treatment, and sequelae, have been found substantially the same, and quite 
identical with those of all other times and countries. Persons of every 
age are liable to it ; the young rather more than the old ; and even infants 
at the breast are by no means exempt. I have not seen but have heard 
of one congenital case. Its attacks are generally preceded by an exciting 
cause ; such as irregularities in diet, or a debauch ; above 'all, getting wet 
and cold, or sleeping exposed to the night air. A long ride through the 
dews of night, or under the hot sun, of an early autumnal day, will alike 
excite it. 

II. Pathology. — I shall not dwell on the pathology of simple intermit- 
tent fever. My firm belief in the existence of a specific, remote cause, has 
been already expressed. The simplest morbid condition which results from 
the action of that cause, is the variety of autumnal fever now under con- 
sideration. To its cause it bears a relation, not unlike that of small-pox, 
.scarlatina, or epidemic cholera, to the agent which produces that malady. 



INTERIOR VALLEY OF NORTH AMERICA. 57 

A stage of reduced and perverted excitement, ending in a chill, with 
shivering of the muscular system, is followed by a reactionary fever, 
which ends in a perspiration, to be succeeded by a state of comparative 
health ; the whole concluded within twenty-four hours. The disease may, 
in one sense, be said to have run its course, when the first paroxysm 
terminates ; and to be, therefore essentially an ephemera. In this respect, 
it might be compared with epilepsy, which has its forming stage (often very 
short), its convulsive stage, and its sleeping stage ; immediately after which 
the patient begins to enjoy his usual health. But, unlike the epileptic fit, 
the paroxysm or fit of fever returns, every day, or every other day, or at 
more distant intervals. In many cases, this repetition, which at the begin- 
ning was daily, comes to be every other day, or every seventh day, or every 
fifteenth j each paroxysm being shorter than the last. But as each has 
added to the disturbance of the constitution, when the disposition to recur- 
rence has ceased, certain consequences may remain. First, an anemic con- 
dition of the blood; second, enlargement of the spleen; third, anasarca ; 
fourth, neuralgia. During the time the paroxysms are thus recurring at 
stated periods, it may be reproduced at irregular intervals, by exposure to 
cold and moisture. When suffered to recur until it ceases spontaneously, 
the patient not unfrequently remains ever afterward free from the malady ; 
although continuing exposed to the action of the remote cause. But 
whether treated or not with medicines, he may experience future attacks of 
neuralgia, with a quotidian or tertian recurrence. 

Simple intermittent fever, never proves fatal but by the lesions which 
the long-continued repetitions of its paroxysms occasions. The most im- 
portant of these have been enumerated. Such being the case we know 
nothing of a particular anatomical character, invariably present in its early 
stages. We know of no organ affected in advance of all the rest, and radia- 
ting a morbid action throughout the whole. We see a disturbance of the 
whole, in which some may suffer more deeply than others ; but with them, 
not before them. We see a deep implication of the nervous system, from 
the first to the last paroxysm, with that kind of involvement of the sangui- 
ferous and secernent systems, which gives us the phenomena of fever; but 
we do not see the symptoms of inflammation — above all, the evidences of 
an antecedent ,'mfl.2iwmation. Such is the disease the treatment of which we 
are now to consider. 



SECTION II. 

TREATMENT OF SIMPLE INTERMITTENTS. 

I. I have met with a number of physicians, who are accustomed to make 
but little effort to arrest simple intermittents, until their patients have expe- 
rienced several paroxysms. The reason assigned for this delay was, that the 
earlier in its course the disease is arrested, the greater is the danger of re- 



58 THE PRINCIPAL DISEASES OF THE 

lapses. This may be true, for the longer time from the application of the 
remote cause, the less will be its impress; but as the habit of recurrence, 
in all periodical diseases, is soon established, as much may be lost from that 
cause, as is gained from the other. Moreover, the patient in whom the 
malady is promptly arrested, soon lays aside every remedy and begins to 
expose himself to exciting causes ; while he who has suffered long, is disposed 
to cling to the former and avoid the latter. On the whole I see no reason 
for delay in resorting to remedies. These I shall include under two heads 
— Preparative and Curative. 

II. Preparative Treatment. — 1. Bloodletting. — In the beginning of 
simple intermittents, we often find much vascular fulness, and during the 
hot stage, a considerable resistance in the pulse, with great heat, thirst, jac- 
titation, headache, backache, and pains in the periosteum of the long bones. 
Such a concourse of symptoms would seem to indicate a phlogistic diathesis ; 
but in reality they are the expression of a febrile condition only, and in a 
few hours will entirely cease, to be renewed the next day, or the next but 
one. Shall we admit that in this condition the lancet is demanded ? The 
answer, I think, should be, that whenever the constitution is vigorous, and 
the physician is called to an early paroxysm, bloodletting is not only 
safe, but will both mitigate the symptoms, and prepare the system of the 
patient for other remedies; which, in many cases fail, or succeed but im- 
perfectly, from the tone and fulness of the vascular system. The blood 
which is drawn is generally free from buff. It has been affirmed that libe- 
ral venesection will of itself cure the disease. This may be true, for sudden 
and copious depletion will produce great changes in the state of the func- 
tions ; under which the disposition of the system to return to the morbid 
condition may be lost. A preference has been given by some physicians* 
to bloodletting in the cold rather than the hot stage. As far as it relates to 
the preparation of the system for subsequent measures, it perhaps makes no 
difference in which stage of the paroxysm the blood is drawn ; but as the 
cold stage is often cut short by the operation, it may be well to resort to it 
in that stage. It is undeniable, however, that the greater number of simple 
intermittents can be, and are arrested, in every part of the Valley, without 
a resort to the lancet. 

2. Emetics. — In the early settlement of the states bordering on the Ohio 
River (constituting what was then called the Western Country), when but 
few Anglo-Americans had, as yet, emigrated into the northern or southern 
portions of the Interior Valley, emetics were among the fashionable remedies 
in the treatment of simple intermittents. At that time, it was the custom of 
every physician whom I knew, to administer them. But for the last twenty- 
five years, they have been discontinued by many, and but seldom prescribed 
by others in this form of fever. Has this disuse arisen from the discovery 
that they are injurious, or even useless? I think not; but from causes 

* Dr. Mcintosh, of Edinburgh, and many practitioners of the Interior Valley. 



INTERIOR VALLEY OF NORTH AMERICA. 59 

entirely different. After the estuaries of the rivers emptying into Lake 
Erie were settled, malignant intermittents mingled themselves with the sim- 
ple ; and, after the states of Mississippi and Alabama became peopled, a 
similar combination was encountered; and it was discovered that emetics, by 
their prostrating influence in these intermittents, often did harm ; and that, 
in the first paroxysms, the simple could not be distinguished from the ma- 
lignant. Under such circumstances, it became prudent to limit the admi- 
nistration of emetics; and as modes of practice are diffusive among the phy- 
sicians of every country, this limitation spread into regions where it was not 
demanded. But another, and, perhaps greater cause of this restriction was, 
the theory that the disease we are considering, is an intermittent gastritis, 
in the treatment of which emetics could not fail to be injurious. To these 
causes we way, I think, ascribe the decline, but not extinction, of the emetic 
practice. 

My own experience, with that of many others, leads me to commend 
emetics in this form of fever. When the circumstances already recognised 
as suggesting venesection exist, let it be first employed — when they do not, 
an emetic may be the first remedy. A free and full evacuation of the 
stomach is followed by a decided improvement in its condition, by a tendency 
to sleep, and an abatement of the dryness of the skin, if not an actual per- 
spiration. The emetic may be given during the hot stage, if the arterial 
system should not be plethoric ; or it may be administered in the intermis- 
sion, or at the access of the chill, which it often shortens, and sometimes 
averts. In fact, when the disease has lasted for a while, a powerful vomit 
just before the shake, is one of the successful modes which the people adopt, 
for arresting the disease. It carries into the system a perturbation, in 
which the paroxysmal tendency is lost. As a preparatory remedy, an 
emetic empties the stomach of undigested food, and the acids resulting from 
indigestion or morbid secretion. Yery commonly, however, instead of acids, 
a liberal quantity of regurgitated bile is thrown up, from the beginning, or 
at the close of the operation. Great comfort, and much abatement of all 
manifestations of disease, generally follow such an operation, and the stomach 
is prepared for the favorable action of other remedies. 

3. Cathartics. — In the commencement of simple intermittent fever, the 
bowels are generally sluggish, if not torpid, and charged with feculent 
matters and bile. A cathartic is, therefore, indispensable, whether an emetic 
be first administered or not. Of this cathartic, calomel should always be an 
ingredient, as a complete emulgence of the hepatic ducts, is a desideratum. 

The old-fashioned dose of ten grains of calomel with ten of jalap, with or 
without one grain of tartarized antimony, is equal to any other formula; but 
calomel, in a dose of ten, fifteen, or twenty grains may be given alone ; and 
after its alterant action has been exerted on the liver, its cathartic effect 
may be quickened by an infusion of senna, with or without sulphate of mag- 
nesia. The best time for the operation to take place is in the decline of the 



60 THE PRINCIPAL DISEASES OF THE 

hot stage. If that stage should be intense or prolonged, the bowels may 
not be obedient to the impress of the medicine, when a liberal bleeding will 
bring on free and full purging. In some cases the liver is in a high state of 
functional excitement; and there is an uncommon development of the ele- 
ments of the bile. Such a condition is indicated by yellowness of the eyes, a 
sallow complexion, and a tongue covered with a heavy yellowish fur, large 
quantities of bile being at the same time brought away by the operation of 
cathartic medicines. It is quite possible, however, to attach too much im- 
portance to the removal of these symptoms, and to be over anxious for a clear 
and healthy tongue before proceeding to other measures. In short, I can see 
no sufficient reason for a continuance, through many days, of a treatment 
which, carried to any extent, will seldom arrest the disease. Indeed, I sup- 
pose it would be better to leave the patient to himself, than by the daily re- 
petition of drastic evacuants, to reduce his strength, and irritate, if not in- 
flame, the mucous membrane of his stomach and bowels; for, if brought into 
such a condition, he would not be prepared, but rendered unfit, for the treat- 
ment which is essentially remedial. 

III. Curative Treatment. — If I should dwell on this head, it will not 
be on account of its difficulty; but for the purpose of discussing a thera- 
peutic principle, and the modus operandi of a medicine, applicable to all the 
varieties of autumnal fever. Tested by their symptoms, obvious pathology, 
and the treatment found most successful, these fevers, I may here repeat, 
cannot be grouped with the phlegmasia, or inflammatory fevers depending on 
common causes, and curable by a routine, antiphlogistic method ; for many 
of them will not yield to that treatment, and others, if sometimes cured, are 
more tractable under a plan, of which that method is but a part. 

As already affirmed, autumnal fever, in all its varieties, is in fact, a pecu- 
liar disease, depending on a specific cause, modified in its nature or effects, 
by causes which are often as little known as the specific cause; and although 
it may cease spontaneously, or be arrested by various means, which establish 
in the system a new action, at the expense of the febrile, it does not follow, 
that among the latter, there may not be some, whose action shall be so anti- 
dotal, that of right they should supplant the others, and be regarded as the 
true and proper remedies. One of these is the cinchona bark, and its pre- 
parations. Before the discovery of the latter, the bark was in general use 
throughout the Valley, and seldom disappointed our expectations ; but the 
fashion of administering it has passed away, and one of the compounds 
formed from it has come into universal use. That compound I shall take, 
therefore, as the representative of the cinchona and all its preparations, in 
the present discussion. 

IV. The Sulphate of Quinine. — This medicine cannot be referred to 
the class of simple diffusive stimulants, such as capsicum or ammonia, which, 
in large doses, excite inflammation and fever ; nor to that of tonics, as gen- 
tian, colomba, and the carbonate of iron ; for although in minute and regu- 



INTERIOR VALLEY OF NORTH AMERICA. 61 

larly repeated doses, it will to a certain degree, excite and sustain the actions 
and energies of the system, these effects are by no means those which cha- 
racterize it, as a therapeutic agent. It has, perhaps, better claims to be ad- 
mitted into the order of sudorifics, for increase of perspiration generally 
follows its administration, if the system and the regimen of the patient be 
favorable to such an effect. With greater propriety, however, it maybe grouped 
with the sedative and antispasmodic narcotics ; but not with the soporific 
division, for it cjtaes not, like opium produce sleep. When its operation, in 
liberal doses, is noticed, it will be observed, to diminish the frequency and 
spasmodic force of the heart's contractions; expand and soften the pulse; 
increase the functions of the skin ; and tranquillize the innervation. Its sin- 
ister effects on the brain, are vertigo ; on the organs of sense, tinnitus aurium 
and temporary hardness of hearing. The last is analogous to the effect of 
some other narcotics, as stramonium and belladonna, on the pupil of the eye. 
In generalizing the phenomena which follow its exhibition in considerable 
portions, we may say that its action is directed more on the great sympa- 
thetic, and the muscular system of the apparatus of organic life, generally, 
than upon the functions of animal life ; another point of distinction between 
it and opium. Two opposite conditions of the system contraindicate its use. 
1st. A high degree of phlogistic diathesis with arterial fulness; 2d. G-reat 
depression of the vital forces. 

The effects which have been ascribed to it, characterize it as a medicine 
which produces, in the innervation, a peculiar change; and constitute it an 
alterant of a particular kind. Now this effect, as experience has shown, stands 
specifically opposed to the effect produced by the cause of the autumnal fever ; 
and on this accidental opposition depends its efficacy, in all the varieties 
(though not all the stages and complications) of that fever. In reference to 
them t it may be said to be antiperiodical and antidotal. It is not, however, 
infallible; for its curative relations to autumnal fever, are like those of 
mercury to syphilis, or of iodine to goitre and external scrofula. If they suc- 
ceed beyond all other known remedies in those diseases, so does the sulphate 
of quinine in the diseases of which we are now treating : — if they, occa- 
sionally, require preparatory and adjuvant treatment, so does it; if they 
sometimes fail, so does the remedy we are considering. 

I have said, that I should take the sulphate of quinine, as the represen- 
tative of the cinchona bark, but it seems proper here to remark, that their 
effects are not precisely the same, though doubtless both act on the same 
principle, in arresting the paroxysms of the Fever. The bark is destitute 
of a diaphoretic property, and acts as an astringent and tonic. A greater 
reduction of the powers of the system, is, therefore, necessary for the suc- 
cessful administration of that medicine, than for the sulphate prepared from 
it ; while on the other hand the bark is best adapted to cases in which 
the vital energies are seriously inpaired. If to these variations we add, that 
when the stomach is irritable, the sulphate may be retained, but the bark 



62 THE PRINCIPAL DISEASES OF THE 

thrown up, we have before us all the data necessary to a practical estimate 
of the relative value of the two medicines, in the present disease ; and omit- 
ting a further reference to the latter, I proceed to speak of the curative 
power of the former. 

1. Omission of Preparatory Treatment. — At the outset it may be asked, 
whether the sulphate of quinine will cure intermittent fever without the 
preparatory treatment which has been recommended ? The answer must 
be that it will ; for in the South it has of late been frequently administered, 
as the first medicine, and found successful. This may seem incredible to 
those, who, adhering rigorously to old ideas, regard evacuation, revulsion, 
and time, as curative; and the sulphate as a tonic, maintaining and carry- 
ing on what they had commenced ; but those who see in that medicine, a 
power of establishing in the system a peculiar action, incompatible with the 
febrile, will have little difficulty in believing the report that it has often 
succeeded, without preparative treatment. Regarding the morbid state of 
the secretions, as the effect and not the cause of the disease, they will con- 
sistently suppose, that the best corrective for that state must ]>e the agent 
which can supersede the febrile action by one of its own. Nevertheless, I 
believe the preliminary treatment, which has been pointed out, generally 
advisable, and in many cases indispensable. This remark, however, applies 
chiefly to the early stages of the disease ; for in relapses, no treatment pre- 
paratory to the administration of the sulphate, is in general required. 

2. Times of Administration. — In traversing the Yalley, I have met with 
respectable physicians who prefer to administer the sulphate in the decline 
of the paroxysm ; others who choose the whole period of apyrexia ; others 
who give it shortly before the access of the cold stage ; others who exhibit 
it indiscriminately through the paroxysm and the intermission ; and all 
referred to experience as the test of their preference. It seems to result 
from this diversity, that it signifies but little, when the medicine is given, 
provided the system be brought and kept under its impress. That a liberal 
dose on the decline of the paroxysm, may promote the sweating which then 
comes on spontaneously, there is no doubt; but it must be borne in mind, 
that the effects of such a dose upon the constitution may pass away, before 
the hour for the next paroxysm. The object in view, is to secure the im- 
pression of the medicine on the general system, at the time when the cold 
stage would form. To this end, it would seem important to make a liberal 
exhibition immediately before that event ; and many who pursue this prac- 
tice regard all that is previously administered, as useless ; others, however, 
apprehend bad effects in the approaching paroxysm, from this administra- 
tion. Relying on my own experience and that of many others, I would say, 
that whatever previous administration may have been made, the important 
period of exhibition is a short time before the access of the paroxysm — for 
then is the struggle, to speak figuratively, between the medicine and the 
disease. The peculiar effects of this agent are temporary, and not like those 



INTERIOR VALLEY OF NORTH AMERICA. 63 

of digitalis, on the heart, or of calomel on the mouth, cumulative. Never- 
theless, evidence is not wanting to show, that the disease may be arrested, 
without a special exhibition at that time; nor is their a want of proof that 
it is safe to give the medicine in the hot stage ; especially if bloodletting 
and purging have preceded its employment. 

3. Doses.— As to the doses in which the medicine should be given, I have 
also found much diversity of opinion and practice. On the whole t^ie people, 
and a majority of our physicians, administer one or two grain doses, at short 
intervals, and the practice is undoubtedly, on the main, successful. In 
protracted cases this mode of exhibition may be the best; but in the early 
stages, and when the object is (as it should be) promptly to arrest the dis- 
ease, occasional large doses are, I think, to be preferred. In a quotidian, 
for example, five or ten grains on the decline of the fever; a similar dose 
six or eight hours afterward, and a third before the access, seem to me the 
best; and the practice is sustained by the experience of many of our most 
eminent physicians. 

4. Required amount. — Much has been said on the quantity necessary to 
arrest a simple intermittent. That it is often given in much larger portions 
than have just been named, is quite certain. But I have met with many 
physicians who regard such an exhibition as prodigal, and declare that the 
characteristic effect is produced, if at all, by a much smaller amount. 
There is a reality in this, as it respects simple intermittents; and where 
there is no reason to fear a lurking malignity, it will be safe to rest upon a 
more limited administration. 

5. Adjuvants. — In regard to the adjuvants, to which recourse may be 
advantageously had, I may say, that if the symptoms should indicate a con- 
siderable degree of biliary derangement, calomel may be advantageously 
combined with the sulphate, and that, when it is given, while the excite- 
ment of the system is yet considerable, or when administered during the hot 
stage, the nitrate of potash may be beneficially united with it, in the pro- 
portion of four grains to one ; or, instead of that refrigerant salt, one grain 
of ipecac may be used. But the most important adjuvant is opium, on the 
use of which I must dwell for a moment. Of the value of this medicine, 
when administered before the access of the paroxysm, the profession has 
long had a just appreciation, though many of our physicians employ it so 
sparingly as to obtain but imperfect results. With my preceptor, Dr. Wil- 
liam Groforth, long among the most popular physicians of the infant settle- 
ments of Kentucky and Ohio, it was a favorite prescription ; and in his 
practice, as well as my own subsequently, I often saw its liberal administra- 
tion in a solid form, an hour or two before the expected paroxysm, so as to 
bring the patient into a state of narcotism before the signs of chilliness 
began to show themselves, productive of the best effects. 

The analogies between opium, and especially between the sulphate of 
morphia and the sulphate of quinine, would lead us to expect such a result. 



64 THE PRINCIPAL DISEASES OF THE 

At the present time, the practitioners of this country very generally unite 
opium with the quinine, which they administer before the paroxysms, but in 
very diiFerent quantities. Of those who are in the habit of giving large 
doses, I may mention Doctors Henry and Merriman, of Springfield, Illinois, 
who give from three to six grains of solid opium, with about the same 
quantity of sulphate of quinine, just before the chill, and find, as they assured 
me, a more certain arrest of the paroxysm than when they omit the opium 
and double or treble the dose of quinine. If an apoplectic tendency should 
be suspected, this practice of course, would be improper ; while in the case 
of an intemperate man it would be almost indispensable. 

6. Continuance of 'the Treatment. — As to the length of time the medicine 
should be continued, it is impossible to speak definitely, without being dog- 
matical. And here I must state, that many persons, including some physi- 
cians, cherish a quasi prejudice against this medicine, on the ground that, 
although it will promptly arrest the paroxysms of an intermittent, they are 
apt to return. In short, that relapses are frequent under its use. My 
inquiries lead me to adopt this opinion. As already said, the anti-periodic 
influence of the quinine is temporary, and when it has passed way, the 
system remaining enervated, slight causes will occasion a relapse. This is 
no objection, however, to the admitted benefits of the medicine, in breaking 
up the morbid catenation ; with which effects, in many instances, the exhi- 
bition of the medicine ceases. If its administration were continued longer, 
many relapses would be prevented. The indication, however, is not precisely 
the same after as before the arrest of the paroxysms. Before they are 
arrested, the object is to establish in the system that peculiar action which 
is incompatible with their reproduction j but after they are interrupted, the 
object is not only to keep up the same action, but to restore the strength, 
and re-establish the functions j to which ends the bark, from its tonic and 
astringent properties, not less than its anti-periodic elements, is much better 
adapted. The right practice then is, after having broken in upon the 
paroxysms with the sulphate, to resort to the bark, and continue its use 
until the atmosphere of early autumn has passed away, and, in cases showing 
great tendency to relapse, throughout the succeeding winter. In general, a 
drachm of the powder taken before each meal will be sufficient. 

Dismissing the bark and its preparations as remedies in simple inter- 
mittent fever, we must now turn our attention to others, on which so much 
need not be said. 

V. Vegetable Bitters. — Many of our native bitters have been more 
or less extensively used to arrest the paroxysms of intermittent fever. The 
favorites are, or have been, the bark of the Cornus Florida, or dogwood ; 
Liriodendron tulipifera, or yellow poplar ; Prunus Virginiana, or wild 
cherry tree, and the herbs Eupatorium perfoliatum, or thoroughwort, and 
Sabbatia angularis (formerly Ohironia ang.~), or American centaury. As 
it was an old professional opinion that the superior efficacy of the cinchona 



INTERIOR VALLEY OF NORTH AMERICA. 65 

bark, over other bitters, arose from the union of an astringent principle, it 
has been customary to combine, with the bark of the trees just mentioned, 
a quantity of oak or some other astringent bark, and to render the whole 
stimulating with wine or whiskey; frequently, indeed, to administer them in 
the form of tincture. 

I cannot doubt that these bitters have often arrested the paroxysms of 
intermittent fever, but it has generally been after the diseases had continued 
for some time, and were kept up partly by debility, and partly by the habit 
of recurrence. Hence the proper time for using them is the period of re- 
storation, after the paroxysms have been interrupted by other means. Of the 
whole, the dogwood has had most reputation ; and, after the alleged discovery 
of a peculiar alkaloid principle in it (cornine), supposed to be analogous to 
quinine, considerable expectation was excited in its favor. I have not myself 
used it, nor have I been able to collect any experience worth detailing. The 
testimony in favor of the eupatorium is, I think, fuller than that bearing on 
the dogwood. A number of physicians have assured me, that they had found 
it a successful anti-periodic ; but no one has spoken so unequivocally as Dr. 
Herbert, of Gallipolis, Ohio. His method is to make a saturated tincture, 
with alcohol, of the leaves and flowers of the plant, and administer it, at 
short intervals, in drachm doses. If the accounts which I have received are 
to be relied upon, it seems probable that this herb contains a peculiar prin- 
ciple, resembling quinine in its effects upon the body. And here I cannot 
refrain from observing, that in a country of such vast extent as ours, many 
parts of which, from their topographical structure, must for ever remain sub- 
ject to intermittent fever, it should be regarded as a duty of patriotism and 
humanity to test, by exhibition and analysis, such of our indigenous plants 
as in their sensible qualities bear any resemblance to the cinchona. He who 
should discover, in our country, a substitute for the bark, out of which the 
sulphate of quinine is manufactured, would be honored as a benefactor. 

VI. Arsenidus Acid. — The extent to which this medicine was employed 
in the intermittent fever of the interior, was greater before than since the 
introduction of the sulphate of quinine. Its minute dose commended it to 
those who disrelished bulky portions of cinchona bark. Since the use of 
the sulphate became general, it is sometimes combined with that medicine, 
and there seems to be no objection, chemical or therapeutic, to the union. 
The arsenious acid has not commonly been administered in the first stages of 
our intermittents ; and, it has seemed to me, perhaps, without sufficient 
reason, as better adapted to cases a little prolonged. It is quite certain that 
it has the power of arresting the parox}'sms, though not so promptly as the 
sulphate of quinine. As its effects, however, are more lasting, it is, perhaps 
not so often followed by relapses. Many of our physicians administer the 
solution of arsenite of potash (Fowler's solution); but I have generally 
given it in substance. The following formula is that which I have been 
accustomed to employ : — 

VOL. II. 5 






66 THE PRINCIPAL DISEASES OP THE 

R. — Arsenious acid, ------ grs. j. 

Finely powdered opium, - grs. iv. 

Mix intimately, and divide into sixteen pills. 

Three or four of these pills, in the course of twenty-four hours, are as 
much as can be long borne. If the disease should not yield, by the time 
the stomach becomes irritable, with some degree of epigastric tenderness, or 
the face exhibits an incipient oedema, it is not advisable to continue the 
medicine any longer. Sixteen grains of sulphate of quinine, added to this 
formula, will make it as effective in obstinate agues, as any other remedy 
with which I am acquainted. 



SECTION III. 

INFLAMMATORY INTERMITTENTS. 

I. Diagnosis and Pathology. — Every autumn, in all parts of the 
Valley, though least in the southern, we see inflammatory mixed up with 
simple intermittents, but they are far less in number. In this respect, how- 
ever, different years vary from each other. Thus, in some seasons, there 
will be very few — in others a large number. There is in such years a 
phlogistic, atmospheric constitution, giving to almost every form of disease 
an inflammatory character. The modification of intermittent fever we are 
now studying, presents us with tension of the pulse, a prolonged hot stage, 
and an imperfect intermission. But the best diagnostic symptoms, are 
those which indicate an inflammation of some organ, generally one of the 
following : — 

1. The Spleen. — The morbid effects of every variety of intermittent 
fever on the spleen, are well known to all physicians. In every one of the 
ten winters that I was connected with the University of Louisville, and 
delivered clinical instruction in the hospital of that city, I met with lesions 
of the capsule of the spleen, produced by inflammation. They were gene- 
rally spots or bands of false membrane. Most of the subjects in which 
they were found had been boatmen ; a class who are exceedingly liable to 
intermittent fever. From these and other facts, I am convinced that sple- 
nitis is frequently present in that disease. It is not, however, the cause, 
but a contingent of the fever ) for the symptoms of splenitis are not present 
at the commencement of any case, as far as I have seen ; and numerous 
cases run through a long course without their occurrence. 

The signs of splenitis are tenderness and pain on pressure over the epi- 
gastric and left hypochondriac regions; especially when the fingers are 
pushed upward behind the cartilages of the ribs ; a slight cough, without 
expectoration, resulting apparently from an extension of the inflammation 
to the diaphragm ; and when the organ is swollen, a dull sound, under per- 



INTERIOR VALLEY Of NORTH AMERICA. 67 

cussion, over the false ribs. When this dulness exists, the case may be 
distinguished from pneumonia by auscultation, which reveals the normal 
respiratory murmur, instead of the crepitus, which characterizes that form 
of pulmonary disease. When splenitis is present, moreover, the intermis- 
sions of the Fever are imperfect, although the chills and even a shake may 
continue to recur. A still further diagnostic sign is to be found in the 
failure of the sulphate of quinine to arrest the paroxysms of the Fever. It 
is not my intention to go further into the history of this inflammation at this 
time, as the disorders of the spleen, produced by autumnal fever, must be 
made the subject of a separate article. 

2. The Stomach. — The mucous membrane of the stomach is occasionally 
the seat of inflammation in these intermittents. But we must not regard 
every instance of irritable stomach as the result of gastritis ; for nausea 
and vomiting may occur independently of inflammation. This is proved by 
their yielding, in some cases, to an emetic, and in others to a liberal admi- 
nistration of opium and the sulphate of quinine, or even to the bark in sub- 
stance. I was assured by Dr. Picket, formerly of Indiana, but now of Mis- 
sissippi, that he had often seen his preceptor, the late enterprising and 
lamented Dr. Perrine, who once practiced in the former state, compel his 
patients, who had irritable stomachs, to hold their hands on their mouths 
and swallow, a second time, the large doses of bark which, before the intro- 
duction of the sulphate of quinine, he was accustomed to administer. 
Nevertheless, that gastritis is sometimes associated with intermittent fever, 
may be regarded as unquestionable ; though the discriminating diagnosis 
between it and mere morbid sensibility of the organ, may be difficult. Ful- 
ness, and great tenderness under pressure and percussion, with nausea and 
embarrassment in the descent of the diaphragm, would undoubtedly require 
us to regard the Fever as complicated with gastritis, especially if these 
symptoms subsisted through an imperfect apyrexia. That this inflamma- 
tion may often extend to the duodenum, giviDg a real gastro-enteritis is, at 
least, extremely probable. 

3. The Liver. — Although less frequently the seat of inflammation than 
the spleen, the liver is perhaps as often, or more frequently, inflamed, than 
the stomach. The hypochondriac tenderness, hacking cough, irritable 
stomach, and sallow or jaundiced eyes, skin, and urine, will sufficiently 
disclose the existence of hepatitis. 

These appear to be the legitimate or characteristic inflammations accom- 
panying this variety of intermittent fever; but there are others, of a con- 
tingent or accidental kind, which must not be overlooked. 

4. The Lungs. — A sudden change of weather may develope pulmonary 
inflammation in connexion with intermittent fever. This will be indicated 
by cough, dyspnoea, pain, and the ordinary auscultatic signs. 

5. The Brain. — If this organ be large, and the chest and neck of the 
patient short ; or if he has had his mind or passions strongly excited before 






68 THE PRINCIPAL DISEASES OF THE 

the onset of the Fever; or should he be subjected to mental perturbations, 
after it has begun, some form of cerebritis may be set up. But we must 
not regard every case of headache, sense of fulness, and delirium, as evi- 
dence of inflammation, for such symptoms are not uncommon, during the 
paroxysm of the simplest intermittent. The acuteness of the symptoms, 
their increase under succussion and depression of the head to the level of 
the body, and their subsistence, though in a diminished degree, through the 
period of intermission, will in general justify the conclusion that inflamma- 
tion exists. If with these symptoms we have variableness in the pulse, a 
certain degree of altered expression, with redness of the eyes, and the 
patient, without being prone to disturbance of mind, under ordinary attacks 
of fever, is acutely delirious, the existence of inflammation would no longer 
be a matter of doubt. 

The reactive effect of a supervening inflammation, on the Fever, is to 
increase its acuteness, prevent a full apyrexia, and transform it into a remit- 
tent; which may be distinguished from an original attack of that kind, by 
the history of its commencement, and by the existing signs of an actual 
inflammation, in some organ. If the inflammation should run high, and, 
especially, if it should have been induced by an external cause, acting on 
the lungs or brain, the Fever may assume a continued type ; and pass for 
an original phlegmasia. The inflammation which attacks the spleen, stomach, 
or liver, above all, the spleen, appears to depend on the same remote cause 
with the Fever; and does not change the type from intermittent to remit- 
tent, to the same extent with the cerebral or pulmonary inflammation. 

II. Treatment. — If in pursuing a routine practice, the sulphate of qui- 
nine be indiscriminately administered, when there is a prevalent atmospheric 
constitution of an inflammatory character, many cases will be aggravated by 
it, and in others it will fail. Venesection should always precede its exhibi- 
tion in such cases ; when, the febrile excitement being reduced, the medicine 
will produce its characteristic anti-periodic effects. 

If, however, one of the organs which have been mentioned, or any other 
should be inflamed, a more extended antiphlogistic treatment will be 
required to prepare the system for the use of quinine. 

Of these inflammations, splenitis yields most readily; a copious bleeding 
followed in some cases with cupping, or a blister, with the cathartics em- 
ployed in simple intermittents, will in most cases prepare the system of the 
patient for a successful administration of the sulphate. 

An associated gastritis gives greater difficulty, and must be more com- 
pletely removed than splenitis, before the quinine is administered. The 
lancet is, of course, indispensable ; and subsequent leeching or cupping on 
the epigastrium, will be followed by more obvious benefits than in splenitis. 
Subsequently a blister to the same region will be of great service. In this 
inflammation calomel is demanded ; and will be found more efficacious in 



INTERIOR VALLEY OF NORTH AMERICA. 69 

large occasional, than in small and repeated doses. The following formula 
will be found convenient — 



]J. — Calomel, 

Powdered Gum Arabic, > aa gr. x, mix. 



I 

White Sugar. * 



To be administered every four hours. The bowels should be opened with 
injections; and all drastic cathartics avoided, together with tartarized anti- 
mony and other emetic medicines. As soon as the inflammation and fever 
begin to abate, one grain of powdered opium may be added to the calomel; 
after which, the quinine may be administered, as in simple intermittents. 

When the Fever is complicated with hepatitis, general and topical bleed- 
ing will be proper ; but their effects, on the whole, will be less satisfactory, 
than in splenitis, gastritis or gastro-enteritis. Antimonials, unless there 
should be a high degree of sympathetic irritability of the stomach, are not 
objectionable; and free purging will prove useful. The regular adminis- 
tration of calomel should, however, be the main reliance. Five-grain doses 
may be given every two or four hours, according to the intensity of the 
symptoms ; and continued till they abate, or a salivation is induced. When 
the inflammation has begun to yield, quinine may be mingled with the calo- 
mel, and will soon arrest the paroxysms. The hepatitis, however, may 
remain in a subacute form, or the liver may fall into a torpid condition and 
give a tardy convalescence. When this happens, one of the following pills, 
taken every six hours, will generally complete the cure — 

R. — Extract of Taraxacum, ----- ^ij. 

Mercurial Blue Mass, ----- gss. 

Sulphate of Quinine, ----- 3ss. 
Mix and make into thirty pills. 

The nitro-muriatic bath to the feet and right hypochondrium, will, also, be 
found serviceable in such cases. 

Should the inflammation be determined upon the lungs, the lancet will 
be indispensable ; to which, if pleuritic pain exist, topical bloodletting, and 
a subsequent blister, may be added. Drastic cathartics will be of little 
value ; but emetic medicines, even to full vomiting, will be proper. Tarta- 
rized antimony in large doses may be given, or the squill, in liberal quanti- 
ties, substituted for it. As the inflammation recedes, the sulphate of quinine 
may be combined with either of the latter medicines, or with any other 
sedative expectorant. 

It is proper, here, to add a word of caution in regard to affections of the 
lungs in connexion with intermittent fever. It is well known, that indi- 
viduals who have experienced attacks of the Fever in autumn, are liable, 
through the following winter, to relapse ; and the change of weather, or 
exposure, which reproduces the intermittent, may generate an inflammation 



70 THE PRINCIPAL DISEASES OE THE 

of the lungs. But in the South, or in very unhealthy places, that which 
seems to be an inflammation is often a mere congestion or sanguineous 
engorgement, returning with the febrile paroxysm. In this pathological 
condition, which may be recognised by the absence of tension in the pulse, 
and by the intermittent tendency of the pulmonary symptoms, the powers 
of the system fail under copious bloodletting ; but full vomiting, with the 
subsequent use of the following compound, may be of great service — 

]J. — Tartarized Antimony, - grs. viii. 

Opium, grs. iv. 

Sulphate of Quinine, - grs. xx. 

Mix and make into eight pills. 

One to be given every two or four hours. In addition a large blister to 
the thorax may be applied with advantage. 

If the inflammation be seated within the cranium, a freer use of the lancet 
should be made, than if seated below the diaphragm. The appearance of the 
blood will assist in the diagnosis of the case, and aid in a decision as to the 
repetition of the bleeding. The usual means of subduing cerebritis, such as 
cupping, elevation of the head, and cold or subtepid effusions, must of course 
be employed. Of medicines, nothing is equal to copious purging with calo- 
mel and jalap ; or with calomel and injections, if the stomach should be too 
irritable to retain the former. The diversion thus created from the brain, 
in connexion with the evacuation of the contents of the lower bowels, will be 
attended with the best effects. Counter-irritation with blisters, should the 
inflammation not speedily yield, will be proper. When an abatement suffi- 
cient to justify it has been effected, the sulphate of quinine must be ad- 
ministered ; but opium, except in minute quantities, or under unmistakable 
signs of constitutional irritability, should not be administered. In the com- 
plication we are now studying, the disease is, as it were, transformed from 
an intermittent into a continued inflammatory fever ; and when the local 
affection is removed, there may not be a return of the paroxysms — if, how- 
ever, they should return, the sulphate of quinine must be administered, as 
for a simple intermittent. 

III. Recapitulation. — I have said all that seems necessary on the 
history and treatment of our simple and inflammatory intermittents, in their 
early stages; but they often assume a chronic form, and occasion more per- 
plexity to the physician than in their earlier periods. Hence our study of 
them is not finished ; but, as malignant intermittents and remittents of every 
kind occasionally terminate in protracted and relapsing intermittents, I pro- 
pose to include the whole under one head, after we have studied all the 
varieties in their early stages. 

But before entering on the next variety, that I may be understood as to 
certain pathological and therapeutic principles which will be carried through 



INTERIOR VALLEY OF NORTH AMERICA. 71 

the whole, it seems advisable, that I should here present them in the form 
of a recapitulation of the two sections through which we have just passed. 

1. The remote cause of intermittent fever makes its impression primarily 
upon the nervous system, producing constitutional depression and irritation, 
followed by febrile reaction. 

2. The reaction lasts less than a day, and is succeeded by a period of 
comparative health; but from the peculiar relation between the remote cause 
and the living system, the depression and irritation recur, and are again fol- 
lowed by reaction. 

3. There is no primary inflammation, nor is inflammation a necessary 
condition of the existence of the Fever • yet it often arises with or supervenes 
on the Fever ; the spleen being the organ oftenest affected, and frequently 
suffering from congestion, and perhaps also, from modes of morbid action 
not yet understood. 

4. In certain seasons, and in the cooler climates, intermittent fever mani- 
fests a higher tone of phlogistic diathesis than in others, although no organ 
may be inflamed. 

5. Intermittent fever is a disease of a specific character, as much as -scar- 
latina, hydrophobia, or scrofula. 

6. The bark, and the salts formed out of its alkaloids, are the true 
remedies — the antidote — the specific. But they are not infallible ; and, in 
many cases, may be aided by certain adjuvants, of which the most important 
is opium. 

7. The object of all the other treatment is to prepare and keep the system 
in a proper condition for the action of the specific. 

8. There are other medicines which may be regarded as imperfect spe- 
cifics, of which the most important are arsenious acid, opium, piperine, and 
the active principle of the Eupatorium perfoliatum. 

9. When the bark or its preparations fail, the failure is generally referable 
to one of two causes — the continued action of the agent which produced the 
Fever, or an obscure inflammation of some organ. 



CHAPTER VI. 

MALIGNANT INTERMITTENT FEVER. 



SECTION I. 

GENERAL HISTORY. 



I shall comprehend, under the term malignant intermittents, all the cases 
known to the Valley, which are not referable to the two preceding heads. 
The members of this group, in their symptoms, differ much more widely 



72 THE PRINCIPAL DISEASES OP THE 

from each other than those of the preceding groups. They are all, however, 
marked with a common character of anomaly or irregularity. The harmony 
of symptoms, both cotemporary and consecutive, observable in the other 
groups, is here wanting; or if displayed at the beginning of a case, is lost 
in its progress. They are still further characterized, in their obvious 
aspects, by a predominance of the cold stage over the hot ; and by a downward 
manifestation of the vital forces and functions, not to be mistaken by the 
most careless observer. They agree, moreover, in occurring chiefly in the 
epidemic period of the year, and in the localities most subject to autumnal 
fever — those which are branded as most insalubrious ; finally, they concur 
in a strong tendency to an early and fatal termination, when not arrested 
by art. 

In different parts of the Valley, they are known/ by the profession, under 
the general appellation of congestive or malignant ; and in their sub-varieties 
by the terms irregular, misplaced, soporose, or algid, according to the pre- 
valence, in particular cases, of this or that anomaly. 

I need scarcely say that this variety of intermittents never constitutes an 
entire epidemic. It is mixed up with the other varieties; and, in most 
localities, the proportion which these cases really bear to the others, is much 
smaller than is generally supposed, at least by the people. Two or three 
circumstances have contributed to swell the catalogue of cases beyond the 
truth. First. When a case of this kind proves fatal, the neighborhood in 
which it happens is thrown into a state of alarm, and every attack of inter- 
mittent which occurs, is liable to be pronounced of the same kind — thus, by 
a stroke of the tongue, simple intermittents are transmuted into malignants. 
Second. There are empirics who are willing to profit by this delusion of the 
people, or even to excite it, and therefore apply the dreaded epithet, con- 
gestive, to ordinary cases, for the purpose of magnifying their skill in 
saving life. Third. Physicians, the most skilful and conscientious, are often 
at a loss to say whether there may not be a lurking malignity in certain 
cases ; and, therefore, prudently speak of them, and prescribe for them, as 
if they were really dangerous ; when, in fact, if let alone, they might take 
the course of common intermittents. 

The regions of the Valley most infested with the fevers of this order, as 
far as I am now prepared to state, are, First. The level portions of Alabama, 
Mississippi, and Louisiana, including the zone of estuaries around the Gulf. 
Second. The southern shore of Lake Michigan, from Chicago round to the 
St. Joseph River, and of Lake St. Clair and Lake Erie, from Lake Huron 
to Lake Ontario, near the estuaries of the creeks and rivers. The interven- 
ing region and the country off to the west of Lake Michigan, are, however, 
not exempt ; but the proportion of cases, with the exception of a few limited 
localities, is much less. 

In the early settlement of the states on the Ohio River, examples of this 
fever now and then occurred, and such is still the case; but neither in early 



INTERIOR VALLEY OF NORTH AMERICA. 73 

nor later times were they numerous, except along the lower third part of that 
river; where they seem to have existed in considerable numbers from the 
beginning of settlement. Relying on the answers to my questions, concern- 
ing the increase or decrease of this fever in the regions where it prevails 
most, I may say that, in latter years, it has been increasing, and that this 
increase appears to date from the visitation of the Epidemic Cholera, in 
1832-4. Still, from the short time that most of the physicians of the -South 
remain in practice, it is difficult to gather up correct data on this subject. 
That the cholera-atmosphere may have had this effect must be admitted. 
It was very perceptible in the vicinity of Cincinnati, for two or three years 
after that visitation ; and the history of epidemics, in all countries and ages 
of the world, coincides with this alleged effect. 

No class of persons is exempt from this form of intermittent fever ; but 
both sexes and all ages are liable ; and, as far as I know, equally so, under 
equal exposure to exciting causes. 

After these general introductory remarks, we must proceed to take a closer 
view of this difficult subject, beginning with its symptoms. 



SECTION II. 



SYMPTOMATOLOGY. 



There is not perhaps in the whole range of symptomatology, a more diffi- 
cult task than that of making a graphical presentation of the symptoms, 
which accompany and characterize our malignant intermittent fevers. This 
results from several causes : First. Their number ; all the functions being 
morbid. Second. Their simultaneous occurrence; as if the whole of the 
organism had been affected by the direct action of the remote cause at the 
same time. Third. The suddenness of their occurrence on the access of 
the paroxysm ; presenting, in a single hour, transition from a state appa- 
rently bordering on health, to one of impending dissolution. Fourth. The 
deep involvement of one great organ in one case — of a different one in 
another, and a consequent modification of the symptoms. Compared in the 
diversity of their phenomena with the most malignant cases of scarlatina, 
typhus gravior, or epidemic cholera, they are decidedly more difficult to 
portray in a methodical and faithful manner than either. Moreover, their 
malignity sometimes shows itself by the slightest possible anomaly. Thus a 
partial numbness, or a coldness of the great toes, instead of a regular chill, 
or a disposition to sleep at the access of the paroxysm, may be all that sug- 
gests anything more than the most harmless intermittent. Hence they 
stand connected, on the one hand, with a simple ague ; while, on the other, 
they graduate into the malignant remittent type, in such a manner that a 
separate description would scarcely be worth the trouble, were it not that a 



74 THE PRINCIPAL DISEASES OF THE 

series of morbid states, however intimately catenated, must be studied in its 
links, before it can be comprehended in its entireness. 

By far the greater number of cases begin as regular intermittents, with a 
cold fit too slight to excite more than a moderate shivering; such, for ex- 
ample, as ushers in a simple remittent. The cold stage, is not followed, 
however, by the well-developed and prolonged hot stage of that variety of 
fever; but by one so inconsiderable, that the patient in many cases is soon 
upon his feet, and often resumes his business till the next day, or the day 
after that. If nothing should have been done, the second paroxysm will be 
more severe; his coldness will be greater and more prolonged, yet not pro- 
ductive of a shake ; he may have a considerable degree of drowsiness, or 
dyspnoea, with a sense of thoracic oppression ; his stomach may become 
irritable, with a sense of epigastric sinking; or some topical sweating may 
show itself. To these symptoms, but more slowly than the day before, will 
succeed a reaction of moderate force, and when it ceases, the patient, if not 
alarmed, will be again out of bed, and, perhaps, occupied. The third, and 
even the fourth paroxj'sm may thus pass away ; each, however, presenting 
an increase of intensity in the symptoms, and a full development of them 
be reserved for the fifth. But this is rare; and, in the majority of cases, the 
third fit not only discloses the danger of the patient, but often proves fatal; 
or he struggles through it, to die in the next. The disease, however, does 
not always advance in this gradual manner. Almost every physician, where 
it prevails extensively, has met with examples of fatal termination in the 
second, and, sometimes, in the first paroxysm. Still further, cases of the 
most simple kind, which, through several recurrences, have shown no sign 
of malignancy, have, under the unadvised operation of an antimonial emetic, 
or an active saline cathartic, proved fatal in the next paroxysm. When 
the dangerous or fatal paroxysm comes on, the functions of the whole body 
seem blighted. 

1. That of innervation is blunted and inactive. But little (and no acute) 
pain is felt in any part of the body ; external applications are not much re- 
garded, and even the cuticle, as I have seen, may be torn off", by rough fric- 
tions, without attracting the attention of the patient, although neither asleep 
nor delirious. The organs of special sensation are equally impaired. The 
intellectual functions, and the feelings, and affections of the mind, are pas- 
sive ; and the expression of the countenance is vacant or stupid. In some 
cases, a considerable degree of delirium supervenes ; but in others, the fa- 
culties of the mind, almost up to the moment of dissolution, show nothing 
more than inactivity. Should there be some degree of delirium, the dispo- 
sition to action will of course be greater. In many cases, however, the 
patient sinks into a coma, from which it is difficult to arouse him, and into 
which he immediately relapses, and continues until the paroxysm passes off, 
or he expires. These of course are the soporose, or apoplectic intermittents 
of systematic writers. 



INTERIOR VALLEY OF NORTH AMERICA. 75 

2. The function of circulation is not less impaired than that of innerva- 
tion. In comatose cases, the pulse is sometimes slow, full, and irregular ; 
but in the majority of cases, it falls rapidly into a state of great feebleness, 
becomes extremely frequent, shrinks in volume, and, finally assumes a 
thready and vermicular character. Before dissolution, it often ceases alto- 
gether in the extremities ; and has been known to be absent for a consider- 
able length of time, in some cases, which have afterward terminated favor- 
ably. 

3. The function of respiration is impaired. The frequency and depth of 
inspirations is reduced; a sense of fulness in the chest is experienced ; and 
sighing, with the restlessness attendant on embarrassed respiration, and an 
insufficient supply of air, supervene. 

4. The digestive functions suffer not less, than those which have been 
named. The state of the tongue is various. Sometimes contracted and 
prismatic; but more commonly of its natural breadth and form; generally 
moist; frequently furred; occasionally red at the tip, but oftener, pale, and 
flabby. The appetite of the patient occasionally continues, in the intermis- 
sions, up to the fatal paroxysm; but oftener gives place to nausea and gas- 
tric irritability ; which, on the access of the fit, may terminate in obstinate 
vomiting ; when he sometimes throws up healthy bile, and now and then a 
fluid of a blue or greenish-blue color. In other cases the fluid ejected is 
acid. The number of cases in which a dark-colored liquid resembling the 
black vomit of yellow fever has been discharged, is so few compared with 
the whole, as scarcely to deserve a recognition ; yet in Peoria, Illinois, I 
saw a patient of Doctor House, who ejected a black liquid from his stomach 
a few hours before death. The bowels are sometimes torpid and costive ; 
but in many cases there is a watery diarrhoea. Xow and then, the matters 
thrown off have resembled the washings of beef; or water colored with in- 
digo. Discharges of blood are exceedingly rare. Of the condition of the 
liver and spleen, otherwise than is indicated of the former, by what has just 
been said of its secretion, nothing special can be recorded. Many patients, 
however, complain of a sense of fulness and anxiety, through the hypochon- 
driac and epigastric regions, and some, especially of the left side, apparently 
indicating' great engorgement of the spleen ; which is doubtless the case, for 
that organ has sometimes been found in a state of manifest enlargement, 
immediately after the recovery of the patient. 

5. The urinary secretion presents considerable variety. Some physicians 
have occasionally seen a great secretion of limpid urine, but in the larger 
number of cases, it is reduced in quantity, and sometimes the secretion is 
nearly suspended. 

6. The function of perspiration is, on the other hand, in most instances, 
greatly augmented — sometimes partial in its extent, more commonly gene- 
ral. The fluid discharged is watery, and may, almost, be seen exuding 
from the skin, which feels cold, inelastic, and doughy ; sometimes it is blood- 



76 THE PRINCIPAL DISEASES OP THE 

less and pale, sometimes the extremities will assume a dark red, and the 
spots on which pressure is made will remain white for a time, indicating 
capillary stagnation. 

7. Lastly, the greatest reduction of energy is, perhaps, in the calorific 
function. The heat of the extremities, and occasionally of the integuments 
of the trunk and head, is signally reduced. It seems as if none were de- 
veloped in the system, and as great exhalation is constantly going on, from 
the surface, external applications, both potential and actual, designed to 
raise the temperature of the extremities, very often produce no effect. In 
the midst of this reduction, the patient will neither shiver nor complain of 
cold, but on the contrary, if not deeply comatose, may declare that he is 
burning up within, and call incessantly for water. Every case, however, is 
not attended with this remarkable loss of heat. Those which manifest it 
most, must be classed with the algid intermittents of the systematic writers. 

A patient in the condition here described, must of course emerge from it 
in a short time, or die. He who might have the greater part of the symp- 
toms, which, for the purpose of a full narrative, have been detailed, cannot, 
of course, be extricated. But a majority of them may be present, and yet 
recovery take place. In no other form of fever could this occur. In this, 
it results from the periodical and paroxysmal character of the disease. As 
the violent symptoms attendant on the cold stage of a simple intermittent, 
give place spontaneously, to those of the hot stage, which, in a few hours, 
as spontaneously cease, and are followed by a complete intermission ; so 
there is, in malignant intermittents, a tendency to reaction and subsequent 
intermission ; and these will occur in every case, in which the depression 
has not gone beyond certain limits, nor any vital organ sustained a lesion 
of structure or function, from which it cannot recover. To this inherent 
and inalienable property, we must ascribe, as to a causa sine qua non, the 
revival of the organism from its depressed and perverted condition : without 
it, the physician would neither have ground for hope, nor encouragement 
to effort. 

Nothing is more common, than for medical gentlemen, where the worst 
cases of this fever prevail, to describe it, as a compound of the cold and hot 
stages ; which, losing their natural relation of sequence, are, to speak para- 
doxically, present at the same time ; the pathological condition of the cold 
stage, prevailing in some of the functions — of the hot stage, in others; 
according as the reaction is not, or is, awakened. No exhibition of symp- 
toms, could more impressively declare the extent to which an external cause 
had violated the laws of the organism. The prognosis of the case, is drawn 
largely from an analysis of these phenomena. In proportion as the signs 
of reaction augment, is the prediction in favor of recovery ; while, according 
to their feebleness, and limited extent through the system, is the prophesy 
of a fatal issue. In a simple intermittent, all the symptoms of the hot 
stage, arise nearly at the same time, and harmonize with each other, while 



INTERIOR VALLEY OF NORTH AMERICA. 77 

they contrast strongly with the equally harmonious concourse of symp- 
toms, which characterized the cold stage an hour before. In the malig- 
nant, both the harmony and the contrast, are replaced, by a discordant 
assemblage of phenomena, which belong to both stages, and will contrast 
with neither. 

In some cases, an abatement of the coma — which may give place to a con- 
siderable degree of intellectual vivacity, with or without delirium, and some 
flush of the face and eyes — will indicate cerebral reaction, while the other 
symptoms of depression may remain. In others, the heart may recover its 
energies, so far as to manifest reaction, and still the capillary circulation 
may not be restored. The respiration may increase in frequency, but the 
color and heat of the surface not be improved. The thirst and sense of 
internal heat may become intense, with augmented epigastric tenderness 
and febrile heat of the trunk of the body, while the extremities may 
remain icy cold. Finally, the exudation from the skin may diminish, a 
feeling of chilliness with shivering come on, or the temperature of the limbs 
become warmer, while many internal functions continue depressed. 

If it be a fatal paroxysm, either of the soporose or algid kind, even these 
feeble manifestations of renovated excitement, may not appear. The occur- 
rence of some of them, moreover, is not a guaranty of recovery; for after 
having lasted for a brief period, they may die away, and death occur, at the 
very hour which a too sanguine hope had fixed for a full development of 
the hot stage. In cases of a less malignant character, some of the pheno- 
mena of the cold stage are apt to continue, anomalously, throughout the 
hot ; and the intermission which succeeds is seldom comfortable or pro- 
mising ; but displays signs of an unhealthy condition of the vital proper- 
ties, or the lesion of some important organ ; giving a melancholy presage 
of the mortal event, which awaits the access of the succeeding fit. In pro- 
portion as the hot stage has been full and intense, and the intermission per- 
fect, is the prospect of safety in the next paroxysm. 

Among the anomalies of this most ataxic fever, I may mention what 
many of my brethren have, occasionally, seen, a transition from the state of 
collapse to that of healthy function, or the third stage, as it is absurdly 
called, manifested in an open and equable pulse, diffused and natural heat, 
a warm perspiration, renovated muscular energies, and sound functions of 
mind. In these cases the hot stage seems, so to speak, to have run its 
course in combination with the cold. They resemble those cases of epidemic 
cholera, which pass from collapse to recovery, without the intervention of 
the long paroxysm of fever, which in other cases succeeds to the stage of 
depression. 

When the patient has been brought out of a severe paroxysm of this fever, 
if neglected or improperly treated, he invariably dies in the next; but under 
judicious management the disease either takes the course of a regular ague, 
or ceasing altogether, a rapid and favorable convalescence ensues, which is 



78 THE PRINCIPAL DISEASES OF THE 

very commonly the case. When, however, any great organ has suffered 
injury during the paroxysm, the recovery will be impeded; and, even, a re- 
lapse may be the consequence. That organ may be the brain, when the intel- 
lectual functions will be, to a certain degree, stultified ; or the lungs, producing 
more or less of cough or dyspnoea ; or the stomach, which will remain irri- 
table, and incapable of a due performance of its functions ) or the bowels — 
affected with diarrhoea ; or the liver, which will mark the system in its own 
peculiar manner ; but of all the organs, the spleen appears to suffer most : 
and often remains enlarged, and sometimes tender for a considerable period 
of time. Thus after all the symptoms of the constitutional disease have 
passed away, those of a local affection may remain. 

As illustrative of several parts of the symptomatology through which we 
have travelled, I will here introduce the following case, which fell under my 
notice in Springfield, Illinois. 

Case. — September 6, 184-i, at 10 o'clock in the morning, was invited by 
Doctor Merriman, to accompany liim in a consultation to which he had been 
called, by one of his brethren. The history of the case, as well as we could 
make it out, was as follows : — The patient, a robust and hale countryman, 
not yet of middle age, residing fifteen miles in the country, felt unwell, on 
the evening of the first instant, while on his way to Springfield, which he 
reached the next morning. He was then chilly, but kept about the town 
till noon, when a fever came on. It abated, and in the evening of the 
second, he had another chill followed by fever. The next day (third), he 
had perspiration and was much better, in which condition he still found 
himself on the morning of the fourth. In the afternoon of that day the 
chill returned, and his hands and feet, with his legs up to his knees, became 
cold, and continued so, till his death. His stomach on that became irritable, 
and he vomited, occasionally, for twenty-four hours, that is, till the evening of 
the fifth. The next morning (sixth), when I saw him, at ten o'clock, he 
was restless in the extreme ) his forehead was warm, but not moist ; his 
face was overspread with a copperish hue ; his eyes were suffused and 
vacant in expression. His hands and wrists were cold and sodden, but 
scarcely moist ; and exhibited the appearance of post-mortem congestion, — 
the dark reddish patches becoming, and for some time remaining, white from 
pressure. His feet and legs displayed nearly the same appearance. The 
trunk of his body had its natural heat. The pulse of the right wrist had 
ceased; that of the left was feeble, moderately full, tolerably regular, and 
one hundred and four in a minute. There was no pulse behind either ankle. 
His carotid arteries beat feebly. The impulse of his heart was weak, and 
the sounds reduced. On percussing his chest, I found the resonance loud 
and hollow, even over the region of the spleen. His respiration was a little 
bronchial. He had frequent sighing, but no cough or hiccup. He had no 
abdominal tumefaction or tenderness, and no diarrhoea. There was some 
ragged fur on his tongue, which, with his gums, had a very tolerable cherry- 



INTERIOR VALLEY OF NORTH AMERICA. 79 

red color. His mind was a little wandering, and he gave some indications 
of false visual perceptions. 

Four hours after I first saw him, that is at two o'clock p. M., his restless- 
ness had increased j his pulse had become smaller, and beat one hundred and 
twenty in a minute ; the coldness and parboiled condition of his hands was 
greater ; and his face at times was pallid. His delirium had, also, increased 
a little ; but he tried, as it appeared, to find his pocket, and, when questioned, 
said he wanted tobacco. Some was handed him, which he put into his 
mouth, and presently used his handkerchief in a natural manner. He then 
lay more quiet, and seemed as though he would sleep. In a short time, he 
asked for the urinal, and after an unsuccessful effort at urinating, handed it 
back. I examined, and found that there was no distension of the bladder. 
He now complained of the irritating applications which had been made to 
his legs two hours before. Such was his situation when I left him, at half 
past three. At four, he became somewhat convulsed, and suddenly expired. 
An hour and a half after death, I found his feet strongly flexed, with a 
knotted contraction of the muscles of his legs, which had continued from the 
time of his dissolution. A post-mortem examination was not permitted. 

A further illustration of the fatal anomalies presented by our intermittent 
fever, is afforded by the following narrative, published by myself, several 
years since. The cases mentioned in it, were probably of the kind which 
should be called apoplectic rather than algid.* 

" Burlington is a small village on the Ohio River, in our own state, 
nearly opposite the mouth of the Great Sandy River, which separates Vir- 
ginia from Kentucky. A family by the name of Cox resided one mile 
below the village, on the north bank of the Ohio River. The shore is high, 
and exempt both from alluvial accumulations and collections of water; but, 
on the opposite side of the river, above the mouth of the Big Sandy, there 
are several large ponds. The people on both sides of the Ohio, including 
those of the village of Burlington, were generally affected with intermittent 
fever. Among the rest, Mr. Cox and every member of his family, amounting 
in all to eight persons, were taken down. He, himself, in the course of the 
disease, was seized with convulsions and delirium, of which he died. One of 
the children, laboring under the fever, became affected with symptoms of 
epidemic cholera, and died. Another, laboring under the same fever, expe- 
rienced an attack with convulsions, like the father, which terminated in 
hemiplegia, from which, however, it has nearly recovered. All these events 
happened at the same place. Soon afterward, the remaining members of 
the family removed to Cincinnati, and fell under the care of Doctor Ridgley. 
One of the children, a boy four or five years old, when the Doctor first saw 
him, appeared to be coming out of the cold stage. He was able to sit up in 
the bed, and converse rationally. But soon after the Doctor left the house, 

Western Journal of the Medical and Physical Sciences (Cincinnati), for July, August, and Septem- 
ber, 1835. Page 372. 



80 THE PRINCIPAL DISEASES OF THE 

he said he was dying, and in fact expired — having complained of severe 
pain in his bowels, a symptom which existed in the paroxysm of the prece- 
ding day. Not long afterward, a daughter, two or three years older, labor- 
ing under the same form of fever, was attacked with convulsions, accom- 
panied with hemiplegia, and after several repetitions, throughout the intervals 
of which she remained senseless, she expired. Two other children and the 
mother are recovering. One of these children, according to the statement 
of the mother, had a paroxysm of the fever when it was but three days old. 
Of the two that died in the city, Doctor Ridgley was permitted to examine 
the body of one only, the boy, but had not an opportunity of inspecting the 
brain or spinal marrow. The mucous membrane of the stomach and bowels 
was free from inflammatory lesions. The liver was unusually firra, and of a 
leaden color. The spleen was dark-colored, engorged, and enlarged. 

" The whole family had been treated, before they came to Cincinnati, with 
the sulphate of quinine, and bloodletting, both general and local, had been 
omitted. The Doctor and myself are of opinion, that the whole, at first, 
required the lancet ; and suppose that to its omission, and the early and 
empirical administration of the sulphate of quinine, the sinister termination 
of most of them might be fairly attributed." 



. SECTION III. 

PATHOLOGY AND COMPLICATIONS. 

I. Pathology. — So much was said in the preceding chapter on the pro- 
duction and pathological character of the first and second stages of autum- 
nal fever, that but little remains to be added here. A malignant paroxysm 
is little else than the cold stage of an ordinary intermittent, deepened and 
prolonged. The innervation is scathed, the circulation is enfeebled ; the 
blood, largely retained from the more external parts, circulates with diffi- 
culty through the internal or visceral system, which is rendered plethoric, 
and the great organs, as the stomach, spleen, liver, lungs, heart, and brain, 
are, respectively, liable to pernicious engorgements or obstructions, greatly 
increasing the danger. A failure in the function of respiration, in the co- 
operative action of the brain, and in the projectile power of the heart, com- 
bine to diminish the aeration of the blood ; which, deteriorated in its con- 
stitution, contributes still further to sink the powers of life. This condition 
of the respiratory function diminishes the heat of the body, which is, more- 
over, reduced by the failure of the calorific function of the skin, from the 
combined lesions of the nervous and circulatory systems; while the ready 
transudation which the relaxed integument permits, of the serous portion of 
the blood, and the copious exhalation which takes place, accelerate the 
cooling. Thus the patient dies under the combined influence of depression 



INTERIOR VALLEY OF NORTH AMERICA. 81 

of the vital forces, and that consequential or accidental engorgement of 
some great organ, which has procured for this fever the epithet, congestive. 
Or should a partial reaction occur — should he survive two or three parox- 
ysms, to expire in a fourth or fifth, as occasionally happens — a low inflam- 
mation may be superadded to passive hyperaemia in the organs most capable 
of reaction, while others remain torpid, and perhaps engorged. 

II. Complications. — The diathesis which is present in our malignant 
intermittents, is observed to manifest its influence in several diseases, which, 
in summer, autumn, or winter, appear where they are endemic. 

1. In July and August, when dysentery prevails, cases occur, and gene- 
rally prove fatal, which by the periodical sinking of the vital powers, evince 
the presence of this condition of the constitution. 

2. During the prevalence of epidemic cholera in the South, the operatives 
on some plantations, died in such numbers, so much in despite of remedies 
employed in the very first stages, and with such a rapid decline of the 
powers of life, as to leave no doubt of the presence of the same influence. 

3. The same thing has happened in the epidemic erysipelas of the last 
few years, several instructive examples of which have been detailed to me. 

4. This diathesis has likewise been observed to modify yellow fever — 
giving it a tendency to a periodical type, and rendering the treatment for 
intermittent fever necessary to the cure of that disease. 

5. But the most frequent and formidable of these complications, is that 
presented by the pneumonias of the South ; and, also, on the shores of the 
Lakes in the North, where numerous cases occur, which the profession too 
often find unmanageable, by any method of treatment they have been able 
to devise. 



SECTION IV. 

TREATMENT IN THE PAROXYSM. 

In most instances, the physician, when first called to a case of malignant 
intermittent, will find the patient in a paroxysm, and his immediate aim will 
ba to produce reaction. For this purpose a great variety of means have been 
tried ; which sufficiently indicates that none of them are very effective. I 
shall begin with — 

I. Evacuants. — 1. Bloodletting. — Some of our physicians, on the 
hypothesis that a malignant intermittent is only the highest grade of gastro- 
enteritis, have bled for the reduction of inflammation, but no success has 
attended the practice; on the contrary, if certain things, injurious in that 
inflammation, were not done after bleeding, the patient perished. 

Others, and a greater number, have bled to promote reaction, by accumu- 
lating the excitability of the system. That, in most forms of disease as well 

VOL. II. 6 



82 THE PRINCIPAL DISEASES OF THE 

as in health, the loss of blood has that effect, seems quite certain. But is it 
followed by such an improved condition of the vital properties and powers in 
malignant intermittents ? That it frequently is, in simple intermittents, when 
a severe chill is rather prolonged, has been shown by Dr. Mackintosh,* 
and the experience of a number of our physicians goes to the same point. 
But does such an effect follow its use in malignant intermittents, unattended 
with great congestion of the lungs or brain ? To this question a large 
majority of our physicians give a negative answer. There is a degree on 
the scale of vital energy, to which the functions often sink in the cold stage 
of this disease, which renders bloodletting not only inefficient as a means of 
restoring the exhausted excitability, but causes the patient to sink more 
rapidly. When the forces of the system are above that grade, when the 
danger from exhaustion and collapse is not imminent, the loss of blood may 
favor reaction ; but precisely, when assistance is most needed, it generally 
fails to afford any. It is to the north, in the basin of the Lakes, as might 
be expected, that the efficacy of this remedy has been most apparent. To 
the south, so great is the enfeeblement of the heart and arterial system, that 
reaction will not in general follow. 

2. Emetics. — It is well known that full and free vomiting is very often 
followed by an increase of the excitability and sensibility of the stomach ; 
and, through it, of the whole system. Hence emetics, prima facie, would 
seem adapted to this stage of malignant intermittents, and they have, in 
fact, been often prescribed. But, on the whole, their effects have not been 
salutary. In cases not very violent, and administered under certain restric- 
tions, they have often, it is true, been followed by early and general reaction; 
but their sinister effects have greatly limited their use, and deserve to be 
recorded. First. The nausea, protracted when the stomach is torpid, which 
precedes vomiting, sinks the powers of the system still lower. Second. 
When the vomiting takes place, it becomes, in certain gastric cases, excessive 
and irrepressible. Third. Instead of vomiting the patient, or after having 
done so, the medicine is apt to turn upon the bowels, and produce a watery 
diarrhoea, or hypercatharsis, under which the patient sinks. This is espe- 
cially true of tartar emetic; which, at the same time, reduces the vital forces ; 
and, therefore, over the South generally, is regarded as a most dangerous 
medicine in this fever. The objections to ipecac, are not so great, and it is, 
occasionally, employed with advantage. Of the whole class, however, the 
stimulating salt and mustard emetic, is the least dangerous, the most likely 
to do good, and the oftenest employed. 

3. Cathartics. — Hydragogue cathartics are regarded as inevitably fatal. 
Doctor Boling, of Montgomery, told me that he had known six patients killed 
with a solution of epsom salts and tartar. In cases preceded by costiveness, 
moderate purging, with blue mass or calomel, combined with extract of 

* Principles and Practice of Medicine. 



INTERIOR VALLEY OF NORTH AMERICA. 83 

scammony, the compound extract of colocynth, and other stimulating cathar- 
tics, or followed by an infusion of senna, with aromatics, with castor oil, or 
as Doctor Ames, of the same place, prefers, the oil of turpentine, is admissi- 
ble during the paroxysm, and occasionally favors the reaction. But, on the 
whole, drastic purging is held to be injurious; and the change which has 
taken place over the West and South, within the last eight or ten years, on 
this point has been signal and decisive. But may not large doses of calomel 
do good ? Of course that medicine will not injure the patient by excess of 
purging; and, a priori, it would seem likely to prove beneficial ; but experi- 
ence has not shown it to possess the power which is demanded in these cases ; 
and, although still in general use, the quantity given is much less than for- 
merly, and the reliance on its efficacy is greatly diminished. 

We must turn from evacuants to stimulants, considering them under 
two heads — external and internal. When the vital forces are so reduced 
that the functions generally fail, and seem likely to cease, a kind of instinct, 
strengthened by experience, turns the attention of the physician, the friend, 
and even the patient, if his mental faculties should not be too much impaired, 
upon something to excite the system. This feeling, not less than observa- 
tion, has prompted to the use of almost every known means of excitation. 
I am sorry to say, they have too often proved altogether ineffectual, and 
sometimes even inert. The susceptibilities of the system are, in many 
cases, so much diminished, that stimuli produce scarcely any more effect, 
than if the patient were actually dead. In cases less deep and dangerous, 
they do good, by creating excitement — the great object to be accomplished 
in the paroxysm. The means employed for this purpose may be divided 
into external and internal. 

II. External Stimulants. — Frictions with the hand, with woollen 
cloths, or with brushes ; pungent liniments, as those containing ammonia, or 
oil of turpentine ; mustard rubbed on dry or applied in the form of a sina- 
pism j a capsicum-bath ; blisters, alcohol, and camphorated spirit, to the 
extremities, epigastrium, or over the spine, are the principal applications. 
It is a fact that these articles will redden the skin, without increasing its 
temperature, or raising the sunken powers of the circulation. The patient 
may even complain of them, and become restless under their action, without 
having the excitement of his constitution elevated. But in this matter a 
physician should be on his guard, for friends and nurses, when a patient is 
extremely ill, are prone to remove from him everything of which he com- 
plains, whereby the expected benefit is sometimes lost. The application of 
sinapisms and blisters to the extremities is often made when the latter are 
so cold and insensible, that no effect can be produced. This is seeming to 
do something, when nothing in fact is done. There are two applications 
which deserve a separate consideration from those we have just enumerated. 

1. Heat. — In a pathological state, so strikingly characterized by reduction 
of temperature, nothing seems more natural than the application of caloric 



84 THE PRINCIPAL DISEASES OP THE 

though the media of air, liquids, and solids. When we are cold, the approach 
to a fire speedily warms us, and we look to the same result in a malignant 
intermittent ; but are often disappointed. The reason is obvious. The orga- 
nized body, living, dying, or dead, is an exceedingly imperfect conductor of 
caloric j and, when we are suddenly warmed after exposure to cold, being at 
the same time in health, it is partly because the loss of caloric was superficial, 
and partly because the applied heat stimulates the calorific functions into 
increased activity, or reaction ; whereby caloric is developed in the structures, 
as well as received by them from without. But in the sunken state of the 
vital properties, this stimulus often fails to re-excite the calorific function, and 
all the warming that follows on our applications, is superficial and tempo- 
rary. Sometimes, indeed, none can be observed, for the great exhalation 
which is going on from the skin, and which is actually promoted by the more 
rapid evaporation of the escaping vapor, under the influence of the caloric 
we apply, tends to prevent any rise of temperature; and this will especially 
be the case when dry heat is applied, and the atmosphere at the same time 
has access to the surface. Baths, extensive cataplasms, or the application of 
flannels wrung out of hot fluids, and so covered with oiled silk or India 
rubber cloth as to prevent evaporation, are, therefore, the best modes of ap- 
plying caloric. Nor need their temperature, in these modes, be many degrees, 
or indeed, any above the natural heat of the body ; as Dr. Edwards* has 
proved that heat tends to destroy the irritability of the muscular fibre, already 
greatly reduced in these cases. 

I have seen immersion in a general hot bath, made stimulating with 
mustard, salt, and whiskey, fail to produce the least reaction ; and have, also, 
seen the entire body wrapped in blankets, wrung out of a spirituous decoc- 
tion of bark equally ineffective, although applied as hot as they could be borne 
by the hands of the nurses, and evaporation from them prevented. 

2. Cold. — The gentleman just quoted has shown that cold tends to pre- 
serve the irritability of the fibre, and what has that effect may, within certain 
limits, be presumed to augment it when reduced. The sudden application of 
cold, moreover, acts strongly on the nerves of the skin, which are endowed 
with a peculiar or specific sensibility to caloric ; if then cold water be thrown 
upon it, excitation will be the consequence, unless the patient be past reac- 
tion ', but the effect will, perhaps, be transient, and by continuing the appli- 
cation too long, the loss of caloric by abstraction may do harm. Finally, 
the cold dash tends to re-excite the languid function of respiration, whereby 
excitement and heat may be generated. There are three modes, then, in 
which cold may prove beneficial in these cases. But not to decide anything 
a priori, when we can appeal to experience, let us inquire into the results 
of this practice. 

The Western Journalf contains a paper by Dr. Achilles Whitlocke, of 
North Alabama, on the cold dash in malignant intermittents, from which I 

* Influence of Physical Agents. t For January, February, and March, 1837. 



INTERIOR VALLEY OP NORTH AMERICA. 85 

make the following extracts : — " The common practice in this region, is to 
repeat the affusion, according to circumstances, until general reaction is 
brought on, which it seldom fails to produce; though like all other remedies, 
it sometimes falls short of our most sanguine expectations. The adminis- 
tration of this agent in the collapse of fever, so far as I am informed, origi- 
nated with Doctor Thomas Fearn, of Huntsville, Alabama; whose reputa- 
tion both as a physician and a surgeon, is too well known to the profession 
in the South, to need my humble testimony. Living in a region of country, 
where the diseases are generally violent, he resolved, as a dernier resort, on 
the experiment of cold water, in the stage of collapse of the disease now 
under consideration, and his experiment was not fruitless, for in numerous 
instances, he and his enlightened colleague, Doctor Erskine, have employed 
it with unprecedented success ; and they do not hesitate to recommend it to 
the profession, as an agent of superior efficacy to any other they have ever 
employed. They further believe, that, where the susceptibility of impres- 
sion is not entirely destroyed, and where no vital organ has sustained an 
irrecoverable injury, the affusion of cold water will in almost every case be 
attended with complete success. To exemplify its effects fully in this malady 
I will here detail a few additional cases, which came under my own care 
and observation, within the last three years." 

The Doctor has given the details of four cases in which the practice was 
successful. I will introduce one as a specimen of the whole : 

" On the third of September, 1834, I was called to see a black man, the 
property of Mr. F., aged thirty-four years, and of good constitution. I 
found him very restless, with a small, quick pulse, of one hundred and thirty 
beats to the minute, and he was bathed in a cold clammy sweat over his 
whole surface ; he complained of great weight in or about the epigastrium, 
had an insatiable thirst for cold drinks only ; his respiration was difficult, 
and his physiognomy shrunken. I learned from the overseer, that he had 
had a chill two days previously, and one on the morning of the present day 
(it was now near night), and had become much worse since the approach of 
the sweating stage. Fully understanding the case, as I thought, I ordered 
some cold well-water to be brought, and immediately poured on his naked 
body about twenty gallons ^having finished, the patient was so much relieved 
as to return to bed without assistance. In a short time his oppression was 
removed, the heat of the surface returned, and he fell into a refreshing 
sleep. His pulse gradually rose, and became open, full, and less frequent, 
his respiration easy, and general reaction was present when he awoke. No- 
thing but the free use of quinine and mild laxatives was afterwards necessary 
to restore him to his former health." 

By extensive inquiry, I have found that this practice is not general, espe- 
cially to the North. Those who have resorted to it, reside chiefly in the South. 
Their reports conflict with each other. A part have found it beneficial — a 
part injurious, no reaction having followed. I may say, of a truth, that the 



86 THE PRINCIPAL DISEASES OE THE 

majority of our physicians, influenced, perhaps, to some extent by popular 
aversion and prejudice, have not employed it. 

The sudden alternation of hot and cold water, would, perhaps, be more 
efficacious than the exclusive use of either. I have not, however, met with 
any physician who had resorted to this powerful means of restoring lost ex- 
citement. 

III. Internal Stimulants. — Almost every kind of excitant and nar- 
cotico-stimulant, has been administered, internally. In this stage of the 
paroxysm of malignant intermittent fever, wine, brandy, whiskey, and other 
alcoholic drinks have been liberally* given ; but the results have not been 
such as to commend them. They probably act unfavorably upon the brain. 
The acrid and aromatic stimulants, such as capsicum, and the oil of black 
pepper, cloves, and cinnamon, are not liable to this objection, and continue 
to be in general use : an evidence that they have not been found prejudicial; 
and doubtless they have sometimes proved serviceable. Camphor and am- 
monia are likewise used; a considerable number of physicians testify in their 
favor. On the whole, however, opium has, perhaps, been more constantly 
employed than any other medicine ; and appears to be harmless (if not very 
obviously beneficial), when not contraindicated by the state of the brain. 
When the bowels are torpid, its use is apocryphal ; but if there be watery 
diarrhoea, by no means an uncommon complication, its effects are every 
way precious ; to obtain them, however, it must be administered in very 
large doses. Finally, the sulphate of quinine has been repeatedly and copi- 
ously prescribed during the paroxysms ; but not, on the whole, with much 
benefit. Such at least is the result of my inquiries ; to which I must add, 
that quite a number of physicians have, as they think, found it injurious, 
from its depressing the vital forces still lower. 

Stimulating and anodyne enemata have not been omitted ; but it seems 
that when the stomach is insusceptible to the action of medicines, the rectum 
is nearly in the same condition. When, however, there is diarrhoea, astrin- 
gent and narcotic injections have done good. 

Such are the measures in general use for establishing reaction, in our 
malignant intermittents. Their variety is great, and they are, in most 
cases, applied with that energy which is characteristic of our physicians ; 
but the results of their employment have never been encouraging; and I 
see no ground of hope for greater success, from the use of other untried 
agents. The difficulty lies in the state of the vital susceptibilities during 
the paroxysm. 

IV. Means of relieving the Internal Organs. — To relieve the 
organs which are in a state of congestion or incipient inflammation, is the 
second object. In the majority of cases, the pathological condition is that 
of congestion only. This condition connects itself with the paroxysm, of 
which it makes in many cases a momentous element. I propose to speak 
of the organs, seriatim, in which it occurs, beginning with — 



INTERIOR VALLEY OF NORTH AMERICA. 87 

1. The Brain. — The affections of this organ manifest themselves, as we 
have seen, by two symptoms — drowsiness and delirium — the former being 
far more common than the latter. All soporose intermittents may be re- 
garded as of an apoplectic character, and should be treated accordingly. The 
remedies are of course substantially the same as for ordinary apoplexy; but 
the character of the fever, of which this is a mere, but most serious con- 
tingent, limits their application, for the vital forces do not admit of their 
being pushed very far. Of the whole, that most deserving of deep con- 
sideration is — 

a. Bloodletting. — After the dissemination in this country, mote than pre- 
viously, of Doctor Mackintosh's recommendation of bloodletting as a means 
of producing speedy reaction, in the more common form of intermittent 
fever, it became fashionable to resort to the lancet in soporose intermittents ; 
and it seems scarcely admissible to omit it. In fact the most beneficial 
effects have frequently followed its use — the coma abating and reaction 
coming on. Nevertheless, it has often failed ; the enervation of the circula- 
tory apparatus, which lies at the foundation of the difficulty, being aug- 
mented by the loss of blood. The cases in which it has been most beneficial, 
were such as presented an anatomical and physiological predisposition to 
apoplexy, with fulness of face, increased heat of the head, and stertorous 
respiration. In the absence of these symptoms, and the presence of mere 
coma with pallor of the face, its effects have been less beneficial, and some- 
times injurious. After venesection, or in cases not seeming to admit of it, 
cupping over the neck and temples, has been employed with decided advan- 
tage. 

b. But, perhaps, nothing, taking the whole range of these soporose inter- 
mittents, has done more good, than the continued application of cold or sub- 
tepid water to the head; while efforts were simultaneously made with hot 
baths to invite blood into the lower extremities. 

c. A sinapism or blister to the nape of the neck, and sometimes to the 
scalp, has been found serviceable. 

d. In these cases the administration of stimulating and drastic purgatives, 
such as aloes, gamboge, calomel, senna, and the oil of turpentine mixed with 
castor oil, is beneficial; and in pursuance of the same object — diverting 
from the brain — irritating injections may be employed. 

2. When the congestion is in the heart and lungs, the dyspnoea, with 
sense of thoracic oppression, is great, and the danger unquestionable. This 
state may, to a considerable extent, coexist with oppression of the brain, to 
the production of which it can indeed contribute ; but many cases are with- 
out coma, and the anxiety and restlessness of the patient is then very great. 
In this pulmonary obstruction, and congestion of the heart, the physician is 
often tempted into the use of the lancet ; and is sometimes rewarded by the 
relief of his patient; but, quite as often is disappointed, no relief to the 
suffering organs being, thereby, procured ; while the powers of the general 



88 THE PRINCIPAL DISEASES OF THE 

system are sunk still lower by the depletion. In addition to bloodletting, 
or as a substitute, scarification and cupping, or extensive dry cupping, over 
the chest may be employed ; after which, the parts may be as extensively 
irritated with sinapisms or blisters. Of internal medicines, ipecac, or that 
medicine with opium, or the wine of ipecac with laudanum and ammoniated 
alcohol, would seem to promise most. I do not know that the inhalation of 
steam, rendered stimulating with vinegar or aromatics, has been tried ; but, 
a priori, it would appear likely to prove beneficial. 

3. The stomach may be the chief seat of local irritation and congestion, 
when incessant vomiting tends still more rapidly to sink the already smitten 
vital forces. In this condition, large doses of calomel, opium, and capsicum 
are most to be relied upon, while epigastric cupping, or strong counter-irri- 
tation, have been found serviceable. 

4. The diarrhoea occasionally present in the malignant paroxysm, may, 
perhaps, be the sign of a congestive tendency to the intestinal mucous mem- 
brane. The prescription just mentioned is proper in such cases; or liberal 
doses of opium and acetate of lead, with astringent and narcotic injections, 
may be employed. 

5. The liver, undoubtedly, suffers very frequently in this paroxysm, be- 
coming engorged and sometimes perceptibly enlarged. The secretion and 
excretion of bile are suspended, and, in some instances, bilious appearances 
manifest themselves in the eyes, the skin, and the urine. Of course, under 
such circumstances, a liberal administration of calomel or the blue mass, with 
or without opium, capsicum, or some other stimulant, is never neglected. I 
do not recollect to have learned that any physician has tried sponging the 
trunk of the body with a hot and strong nitro-muriatic solution, in such 
cases ; but, as it would be a powerful counter-irritant, and might exert some 
specific influence on the liver, it seems worthy of a trial. 

6. That the spleen is generally engorged in malignant paroxysms, can 
scarcely be doubted. It sometimes projects beyond the cartilages of the ribs 
during the paroxysms, and, of all the sequelae of the disease, an enlarged 
spleen is the most common; almost the only one, indeed, which remains for 
any considerable time. Of the different congestions, this is, perhaps, the 
least dangerous; and may even save more important organs from the same 
pathological condition.* I know of no special treatment directed upon this 
organ during the paroxysm. 

Such are the chief local affections attending the malignant paroxysm, and 
the most approved means of removing them employed by our physicians. 
That these local affections often prolong the paroxysm, and increase the 
difficulty of exciting reaction, must be admitted. It is still more obvious, 
that they are frequently the immediate cause of death, especially when 
seated in the brain or lungs. I have spoken of them as simple congestions, 
but post-mortem examinations in Europe have demonstrated, that in the 

* Doctor Rush. 



INTERIOR VALLEY OE NORTH AMERICA. 89 

malignant interniittents of that continent, traces of inflammation, in all the 
organs mentioned, have been found; and, therefore, we must conclude that 
it occurs on this continent. In general, however, the inflammatory action 
must of necessity be feeble ; and cannot be admitted to be the cause of 
death, in those who die in the first malignant paroxysm. An inflammation 
may commence with the coming on of reaction ; and, continuing compara- 
tively dormant, through the intermission, acquire greater intensity in the 
succeeding fit, notwithstanding the sunken powers of the system. Thus its 
ravages are most likely to be found, in those who die after several parox- 
ysms. Should the inflammation supervene at an early period, and acquire 
considerable activity, it changes the diathesis from a malignant to an inflam- 
matory type, and in that way may prove salutary. When signs of inflam- 
mation supervene, the remedies appropriate to its particular seat, must be 
employed to an extent commensurate with its intensity ; but the physician 
should never forget, that he is dealing with a paroxysmal disease, and that 
he must employ the antiperiodic treatment not less than antiphlogistic. 



SECTION V. 



TREATMENT IN THE INTERMISSION. 



All the medicines required in the intermission, have been enumerated, as 
portions of the long catalogue which have been employed, with but little 
effect, in the paroxysm. The most important are the bark and the sulphate 
of quinine, opium, calomel, arsenic, and certain aromatics. 

I. Bark and the Sulphate oe Quinine. — Before the introduction of 
the sulphate of quinine, the bark, administered in large doses, was found a 
successful remedy in this variety of fever. I have often seen from two to 
four ounces, administered in a single intermission ; but such quantities 
were swallowed with reluctance, and sometimes thrown up by the stomach. 
Under such circumstances, the medicine was often mingled with injections, 
and effected a cure. Doctor Hays, now of Indiana, who thirty years ago 
practised his profession in Chillicothe, Ohio, where malignant intermittents 
prevailed, has lately informed me, that he often administered four ounces of 
bark in that way with the happiest effect. 

The sulphate of quinine is not, however, obnoxious to these objections; 
and at the same time is probably more efficient; I shall, therefore, confine 
what I am about to say, to that preparation. 

1. Time of Exhibition. — The concurrent experience of our physicians, 
declares that this medicine is an effectual remedy, in malignant intermittent 
fever, if properly administered in the intermissions ; yet. there are circum- 
stances which frequently interfere with its success; or, to speak more 
definitely, either occasion or permit a fatal termination. To these circum- 
stances we must now turn our attention. 



90 THE PRINCIPAL DISEASES OF THE 

a. We have already seen, that the sulphate will not produce its specific 
influence, if administered in the paroxysm. Now it sometimes happens in 
quotidians or double tertians, that the intermission is so short and imperfect, 
that the medicine cannot make its proper impression on the system. 

b. When the hyperemia, either passive or active, of some great organ, 
survives the paroxysm, it may prevent the successful administration of the 
medicine in the intermission. 

c. In cases accompanied with gastric irritability, the stomach may refuse 
to retain a sufficient amount of the medicine, to arrest the paroxysms. 

d. The physician may be called in, when the access of the fit is so near, 
that the recurring debility of the system may be established, before the 
medicine which he administers can take effect. 

e. He may, through ignorance, timidity, or a false theory, exhibit the 
medicine, in insufficient doses. 

f. A predisposition to apoplexy, or habitual feebleness of constitution, 
may render the exhibition ineffectual. 

g. Do morbid accumulations in the stomach ever countervail the bene- 
ficial influence of the medicine ? It cannot be doubted, that an alterant of 
any kind, is more effective, if the stomach be empty ; but such a condition 
of the organ as follows the operation of an emetic or cathartic, cannot be 
regarded as indispensable to the successful action of the sulphate. If 
patients have died, because of an unprepared state of the stomach when the 
medicine was given, I cannot doubt, that a still greater number have been 
lost, by the delay and the debility occasioned by a course of evacuation 
from the stomach and bowels, designed to prepare them for the reception of 
the antidote. 

The physician who suspects that he is grappling with a malignant inter- 
mittent, should be on his guard in reference to such evacuations. He should 
fully realize the great truth, that antimonial preparations and saline cathar- 
tics, are often the immediate, or exciting causes, of a malignant paroxysm; 
and that cases, apparently, of the simplest character, are often transformed 
into the most dangerous, by their debilitating influence. 

2. Quantity and Intervals of Exhibition. — When the sulphate of quinine 
was first introduced among us, it was given in one or two grain doses, in 
ordinary intermittents, and, seldom, in more than double that quantity, for 
the arrest of the most malignant. The periods of exhibition were every two, 
four, or six hours, according to the apparent gravity of each case. But 
although such portions might have proved successful in ordinary inter- 
mittents, they were soon found to be insufficient for the malignant; and the 
practice of giving the medicine, in what would once have been regarded as 
fatal portions, is now almost universal. Yet, even at an early period, a few 
physicians went far ahead of their brethren ; and the late respectable Doctor 
Perrine, deserves to be named as one who, twenty-five years ago, in the State 
of Indiana, led the way in this bold medication. To make known the extent 



INTERIOR VALLEY OF NORTH AMERICA. 91 

to which this medicine is prescribed by many of our physicians, and, also, 
to show, that in quantities far beyond the limits of ordinary practice, it does 
not occasion any permanent bad effects, I will mention the doses in which 
it is given by many of our physicians. 

On the southern shore of Lake Erie, Doctor Tilden, of Sandusky, told me 
he has given forty grains at once ; Doctor Manter, and Doctor Howard, of 
Elyria, sometimes administer half or two-thirds of that quantity at a single 
dose, to be repeated every two hours, through the intermission. These 
gentlemen practise in the latitude of forty-one degrees and thirty minutes. 
At Memphis, near the thirty-fifth degree, Doctor Shanks administers the 
same portions, and has sometimes given twenty grains at once. Between the 
thirty-third and thirty- second degree, in Mississippi and Alabama, Doctor 
Yongue has given, in a single intermission, as much as fifty grains, in ten- 
grain doses; Doctor Davis, ten grains every hour, or every other hour; 
Doctor Dancy, from five to fifteen grains at once, repeated occasionally ; 
Doctor Street, from ten to fifteen grains, in the same way ; Doctor English 
frequently administers from thirty to forty grains in four' or six hours ; 
Doctor Echols, in anticipation of a paroxysm, took twenty grains at a single 
dose. The fit was averted, and perspiration came on, with a slow and full 
pulse; Doctor Sims often administers it in ten-grain doses, frequently re- 
peated ; and Dr. Boling regards that dose as rather large, though he has 
administered fifteen or twenty at once, and knew forty to be taken in one 
intermission. But the boldest exhibition seems to have been made in 
Florida, between the thirtieth and twenty-seventh parallels, by some of our 
army surgeons. The Assistant-Surgeon, Holmes, has administered twenty, 
fifty, and even eighty grains at once; and Surgeon Harney, one of the 
senior, and most authoritative members of the medical staff of our army, 
has given from thirty to sixty grains at a dose, and thinks the larger the 
portion the better. It is probable that so many of our soldiers are, or have 
been, intemperate, that they can bear, or may even require, larger doses than 
are demanded in private practice. To these facts, intended to show the up- 
ward limit of the sulphate in our Valley, and at the same time its harmless- 
ness in large quantities, I may, in reference to the latter, add the following : 
A man in Cincinnati, by mistake, took two drachms of the sulphate, without 
injury; a patient of Doctor Sappington, of Memphis, Tenn., who had a re- 
lapsing intermittent, took eighty grains at once instead of taking it in eight 
doses, as ordered, but was not injured; Doctor Fair, of Montgomery, Ala., 
has told me of a patient, who took an ounce in three days, and recovered ; 
and Doctor Hiriart, of Plaquemine, Louisiana, knew of an old lady, laboring 
under an algid intermittent, who took ten grain doses, every two hours, till 
an ounce was swallowed. No bad effects occurred and she recovered. 

But are the large doses which have been mentioned really necessary to 
arrest the paroxysm of a malignant intermittent ? To this question I would 
reply: First. That a majority of our physicians do not resort to such por- 



92 THE PRINCIPAL DISEASES OF THE 

tions, yet claim as much success as those who do ; and I know not that their 
claim is groundless. Second. But in very violent and dangerous cases, as 
the medicine may be administered in great doses without any empoisoning 
effects, it would certainly be prudent to give it liberally. 

In ordinary cases, a scruple taken in one intermission, will, I think, ac- 
cording to the experience of our profession, be found sufficient; and with 
the adjuvants to be presently mentioned, even half that quantity may often 
answer. But in cases of a threatening character, forty or sixty grains should 
be given in the same space of time. Whether any advantage is ever derived 
from going beyond that quantity, is, I suppose, an open question. 

Much diversity of opinion and practice exists among us as to the distri- 
bution of the medicine through the period of intermission. I need not re- 
peat what was said on this subject, when speaking of simple intermittents. 
My own mind inclines to large doses, and long intervals \ but, whichever 
may be adopted, the patient's system should be strongly impressed by the 
medicine, at the time for the recurrence of the paroxysm ; and to secure 
this, a good proportion of what is used should be administered a couple of 
hours before the end of the intermission. Thus, if a scruple should be the 
aggregate quantity, one half ought to precede the chill, and whether the 
other half should be given in ten, five, or two grain doses, is, perhaps, a 
matter of indifference. 

II. Opium, or the Sulphate or Morphia, is in general use as an 
adjuvant to the sulphate of quinine, in our malignant intermittents. Of its 
great value no physician of experience, in those diseases, can entertain a 
doubt. If there be no diarrhoea, however, it is not necessary to administer 
it throughout the intermission, but reserve it for the last dose of the sul- 
phate, before the approaching chill. The quantity in which it is then given 
is often entirely too small, and much better fitted to simple intermittents, 
in which the susceptibilities of the system are lively, than to those in which 
they are greatly reduced. In such a state of the system, three or four times 
as much as would be required in an ordinary ague, is not a large dose. I 
have met with many physicians who had a just appreciation of this state of 
the system ; but with none who carried the practice, logically deducible from 
it, so far as Doctor Merriman and Doctor Henry, of Springfield, Illinois. 
It has grown into a settled opinion with those gentlemen, that a moderate 
quantity of the sulphate, combined with a large quantity of opium, is the 
very best practice. Hence through the early periods of the intermission, 
they do little or nothing ; but, three or four hours before the chill, admi- 
nister a bolus of four grains of opium and eight grains of the sulphate, 
which, as they affirm, scarcely ever fails. Dr. Henry has even found that 
doses of opium, without the other medicine, successful. Doctor Jayne pur- 
sues the same practice, but generally limits the opium to two grains. While 
I was in Springfield, the next morning after the death of the man whose 
case is given, page 78, and who had not been treated on this plan, Doctor 



INTERIOR VALLEY OP NORTH AMERICA. 93 

Merriman invited me to see one of his own patients. She had labored for 
several days, apparently, under an ordinary quotidian, and, by the advice of 
an empiric, had been copiously purged. This brought on a very dangerous 
paroxysm, from which, however, she recovered, before Doctor Merriman 
was called in. As it recurred in the morning, he directed that, in the lat- 
ter part of the night, she should take his ordinary portion of four grains of 
opium, and eight of sulphate of quinine. At nine, A.M., four hours after- 
ward, I saw her. She had a slight degree of drowsiness, said she felt com- 
fortable, her eyes were a little red, her pulse was well sustained, and her 
skin pleasantly warm. The next morning I called again, and learned that 
the paroxysm had been averted, and she was recovering. Doctor Shanks, 
of Memphis, has also found opium very valuable, but distributes it through- 
out the intermission. He has given as high as twenty-four grains, in the 
twenty-four hours, with decided advantage. 

Neither my own experience, nor the facts I have been able to collect from 
others, enable me to decide between opium and the sulphate of morphine, in 
the treatment of malignant intermittents. The former is, perhaps, the more 
durable, the latter more coincident with the sulphate of quinine, in its effects. 
In many cases its limited bulk may render its administration easier than, 
that of opium. 

III. Arsenious Acid. — I have met with a few physicians who had 
combined arsenious acid with the sulphate of quinine, in the treatment of 
malignant intermittents, and found it beneficial. Whether, in union with 
opium, the sulphate being emitted, that compound would succeed, is not 
known. When the approved anti-periodic is scarce, it would certainly be 
well to give opium and arsenious acid, liberally, throughout the intermission, 
and the sulphate with opium near its close. In such cases, the arsenic 
should be used in larger doses than for simple agues. An eighth of a grain, 
with a grain of opium every two hours, could not be too much. 

IY. Piperine and the Oil of Black Pepper have been added to the 
sulphate of quinine ; and many physicians think well of the addition, espe- 
cially of the latter. I am not aware, that either of them has been relied 
upon to the exclusion of the sulphate. Capsicum, in doses of two or ten 
grains, has been combined with the latter; and, in cases of great exhaustion, 
the union of that local stimulant may give effect to the principal medicine. 

Y. Calomel is a common adjuvant of the sulphate; and a favorite pre- 
scription with some, is a bolus of ten grains of each of those medicines, and 
a grain of opium every two or three hours ; during the intermission, when 
there is a watery diarrhoea, or signs of engorgement, torpidity, or other de- 
rangement of the liver, the use of calomel or the blue mass is certainly in- 
dicated ; but, in the absence of such symptoms, that medicine does not 
appear to be required ; as it certainly exerts no power as an anti-periodic, 
whatever may be its value as an antiphlogistic. 

VI. Regimen and Relapses. — Whatever modification of the treatment 



94 THE PRINCIPAL DISEASES OP THE 

here detailed may be adopted, I cannot doubt the indispensable necessity of 
the patient being kept in bed, and restrained from conversation and every 
kind of occupation, for the purpose of maintaining the warmth and capillary 
circulation of the skin, and promoting a gentle but sustained diaphoresis. 
Through the ignorance and restlessness of patients, seen but seldom by 
their physicians, from being scattered over the country, these salutary obser- 
vances are perpetually violated, and the wisest methods of treatment thereby 
rendered abortive. Nothing is commoner, than for men to be walking about 
up to the access of a most dangerous paroxysm. A man, whose case was 
mentioned to me, stood up and shaved himself only fourteen hours before he 
expired ; and many undress themselves and go to bed, to die before the next 
day. No sound pathologist would expect to see a patient, who kept on his 
feet during the intermission of such a disease, preserved from its fatal effects. 
After having escaped one paroxysm, the necessity for close confinement is 
less urgent; but, still, before the period for the next, the patient should be 
warm in bed, and if possible, asleep. 

In some cases a relapse may be malignant, when the original attack was 
simple ) of which I saw an example in a patient of Doctor Rouse, Peoria, 
Illinois : — 

Case. — Maynard, a citizen of Kaskaskia, in that state, suffered an attack 
of intermittent fever, from which he had tolerably well recovered, when he 
set off to Peoria. On the journey he was exposed to a hot sun and relapsed. 
On the 14th of September, 1844, when Doctor Rouse saw him, in the 
paroxysm, he had copious vomiting and purging of bile, and was very cold. 
On the 15th he experienced another paroxysm of the same kind. On the 
16th when I was invited to see him, he was in a third. I found him nearly 
pulseless, and the force of his heart very feeble. His respiration was bron- 
chial, and attended with a kind of vibratory purring, recognisable both by 
the hand and ear. His extremities and tongue were cold. The latter was 
moist, and stained of a dark color, by a fluid, which resembled finely pow- 
dered coffee-grounds, mixed with mucus, which he brought up by a kind of 
eructation. His intellectual functions were nearly unimpaired, though he 
died an hour afterward. 



SECTION VI. 

CONCLUSION. 

I shall conclude the subject of malignant intermittents with the following 
observations : — 

I. I have several times used the word collapse, to indicate the state of 
the system in a very dangerous or fatal paroxysm. Since the year 1832, 
that term has been associated in the public mind with epidemic cholera, and 
can scarcely be used without suggesting that disease. In employing it in 



INTERIOR VALLEY OF NORTH AMERICA. 95 

the history of malignant intermittent fever, it is by no means misapplied ; 
for the failure in the power of the heart, the reduction of animal heat, the 
stasis of blood in the skin of the extremities, and the post-mortem spasmodic 
contraction of the muscles of the extremities, observed in some instances, 
are so many points of identity in the two diseases. But there are still some 
others. Thus, as we have seen, the subject of malignant intermittent fever 
may keep on his feet, and even attend to business, up to the access of the 
fatal paroxysm, as the victim of cholera is wont to do, while laboring under 
the diarrhoea, which may be followed by collapse and death in a few hours. 
Such patients seem alike unconscious of their condition, and incredulous 
of the predictions of danger. In the final stage, when death is impending, 
their intellectual functions are often unimpaired, or simply reduced to an 
aspect of stolidity, while their feelings and emotions are subdued into apathy. 
Further, these maladies, so constantly fatal when they reach a certain stage, 
are, even immediately before its arrival, controllable by very simple and 
nearly the same measures. Finally cadaveric examinations have disclosed 
occasional vestiges of inflammation in both, but not of sufficient extent to 
account for the fatal termination. 

There are, however, two striking differences. First. The Fever has an 
indigenous cause, annually reproduced, and is confined to certain localities; 
but the cholera depends on a cause, which occasionally visits countries dis- 
tant from those in which it is elaborated. Second. The Fever is, essentially, 
periodical, while the cholera consists of a single paroxysm. 

II. The well known fact, that in the midst of many cases of simple inter- 
mittent, not proving fatal, although but little shall be done, there may be 
a few which assume a malignant character, perplexes both physicians and 
the people. But this trait of character is not peculiar to that fever. It is 
equally true of yellow fever, cholera, scarlatina, and all other diseases which 
have an epidemic prevalence. The whole, in this respect, are under one 
law, which doubtless connects itself in part with diversities of constitution. 



CHAPTER VII. 

REMITTENT AUTUMNAL FEVER— SIMPLE AND INFLAMMATORY, 
CONSIDERED TOGETHER. 



SECTION I. 

SYMPTOMS. 



I. Diagnosis. — If we suppose an ague-shake to be reduced to a mere 
chill, but the subsequent hot stage aggravated and prolonged, we shall form 
a just conception of the relations, in symptomatology, between intermittent 



96 THE PRINCIPAL DISEASES OF THE 

and remittent fever. We have studied the former under two heads, but I 
propose, in treating of the latter, to blend under one head, all the cases 
which are not designated as congestive or malignant. 

In general, a remittent is preceded by a forming stage of one, two, or 
three days, in which there is an increasing languor of the muscular system ; 
inefficiency of body and mind; defective perspiration; rigors, sometimes 
alternating with flushes of heat ; a torpid state of the bowels ; increased or 
diminished secretion of bile ; a bilious hue of the eyes ; loss of appetite, 
nausea, and in many cases bilious vomitings ; a foul and generally white 
tongue, having sometimes a tint of yellow; in most instances a dull pain in 
the head and back. After these and various kindred symptoms of debility 
and perversion, in the different organs of the body, have continued for a 
while, the rigors are, as it were, concentrated into a chill, which may or may 
not amount to shivering ; the patient now becomes thirsty, or, if so before, 
the desire is increased ; his nausea is generally augmented ; his pulse in- 
creases in frequency, and his headache grows worse. In a few minutes, or 
an hour or two, the chilliness ceases, and is succeeded by febrile heat, over 
the whole surface, but especially in the head, the pain in which, as in the 
back, becomes more acute ; the mouth loses much of its moisture ; the white 
fur on the tongue rapidly augments; the epigastrium becomes tender; the 
secretion of urine lessens ; and the pulse acquires preternatural frequency, 
force, and fulness : there is also intolerance of hot and confined air ; a ten- 
dency to deep inspiration, or sighing, and great restlessness. The chill 
generally occurs between midnight and noon, commonly in the forenoon, 
and the hot stage, of which I have drawn the character in brief outline, 
runs on till after midnight, when it begins to abate ; and, by morning, the 
patient is found with greatly diminished heat, and a limited perspiration ; 
his pulse has become slower, and lost its preternatural force ; his thirst has 
diminished, and he is more or less inclined to sleep. Feelings of health, 
however, are not present ; there remains a dull aching of the head and back ; 
the epigastrium is more or less tender, and pressure upon it may excite 
nausea ; in short the patient has not passed into a state of intermission ; 
but returned nearly into the condition which preceded the chill, the day 
before. After continuing in this state a few hours, an increase of thirst, 
headache and frequency of the pulse, usher in a second chill, which, instead 
of being more, is often less violent, than the first; and is soon succeeded by 
the full development of a hot stage, commonly more intense than the pre- 
ceding; which is succeeded by a remission, not quite as great as that which 
followed the first paroxysm. In this manner, the exacerbations and remis- 
sions, are repeated daily ; the former being sometimes more violent every 
other day, giving to the case the character of a double tertian. 

II. Tendencies and Terminations. — 1. Mild attacks, in persons of 
good constitution, even when but little is done to moderate their violence, 



INTERIOR VALLEY OF NORTH AMERICA. 97 

will, in many cases, terminate by a sort of crisis at some period of the second 
week, and recovery or a regular intermittent follow. 

2. In more violent attacks, it may soon be discovered that some organ is 
becoming inflamed. The one which is, perhaps, more frequently attacked 
than any other, is the spleen ; but that organ does not always make known 
its condition ; next to it, in the opinion of many, is the liver, of which the 
inflammation is less obscure in its signs; then come the stomach and duo- 
denum ; then the head, and lastly, the lungs. In proportion to the inten- 
sity of the inflammation thus awakened, is the danger of the case ; and those 
who perish within the second week, generally die of inflammation of some 
great organ. 

3. Passing beyond the period here mentioned, the disease may lose its 
acuteness and periodicity, and begin to exhibit typhous symptoms, which 
may gradually increase, until a fatal termination occurs at the end of two, 
three, or four weeks. In this condition a close diagnostic inspection will 
generally discover some organ in a state of subacute inflammation, and the 
one, perhaps, the most frequently involved is the brain : but more of this 
hereafter. 

4. In some cases, especially in the South, it is observed, that after a few 
regular paroxysms, the hands and feet will continue cold through the hot 
stage, and only recover their heat in the remission ; and this, with other 
symptoms to be mentioned elsewhere, indicate to the experienced observer, 
congestion of some of the great organs, continuing throughout the whole 
twenty-four hours, and admonishes him, that he has to deal with a lurking 
malignancy. 

5. Far in the North, remittent fever often presents, almost from the begin- 
ning, a tendency to the continued type, displaying the characteristics of the 
synochus of Cullen's Nosology. It is properly called autumnal fever, because 
it prevails most in that season, and is an equivalent for the true remittent 
fever of the warmer climates. Nearly the same remark is applicable to this 
fever, when in the middle latitudes it appears in the long-cultivated and 
drier portions of Tennessee, Kentucky, Western Pennsylvania, and Ohio. 
Formerly it often abated into an intermittent ; latterly, it is apt to degenerate 
into a continued type. 

6. All these tendencies and modes of termination may occur in the same 
locality, and in the same autumn ; but some are more common in one place, 
others in another. Moreover, in one season, the case may be generally mild 
and simple ; in another, highly inflammatory ; in another, disposed to assume 
a typhous character ; in another, a malignant or congestive type. 



i 



98 THE PRINCIPAL DISEASES OF THE 

SECTION II. 

TREATMENT. 

The concise history of the symptoms and pathology of simple and inflam- 
matory remittent fever, which I have sketched belongs to the middle latitudes 
rather than the northern ; where, as we have seen, the tendency to a con- 
tinued form prevails ; or the southern, where the malignant or congestive 
type most frequently manifests itself. And what I am about to say on the 
treatment, will apply more aptly to the fever of our temperate climates than 
any others. 

I propose to speak successively, of the various methods of cure which 
have been in vogue among us; and as far as possible assign the principle on 
which each was based : — 

A reference to the times of settlement of the Interior Valley ( Vol. I. Book I. 
Part III.) will show that, with the exception of the French and Spanish 
inhabitants around the Gulf of Mexico, and the French and British on the 
St. Lawrence and the Lakes, nearly all the settlements of the Valley have 
been made within the present century ; it is possible, therefore, to review 
the plan of treatment from the commencement of western society, which 
cannot be done in any other part of the world where larger masses of popu- 
lation exist. • 

I. First Treatment in the West. — There has never been a time 
when our fever was regarded and treated, as a simple inflammatory affection 
— a mere phlegmasia. In the earliest period of immigration, it was believed 
to have something in its pathology, which required other agencies than the 
antiphlogistic, although a portion of that treatment might be requisite. 
Two facts, especially fixed the attention of the physicians of that day : 
First. The derangement of the biliary function : Second. The inherent 
periodicity of the Fever ; and these facts suggested the treatment. The 
disordered functional action of the liver was to be corrected ; the stomach 
and bowels relieved from their morbid secretions ; the arterial excitement 
reduced until intermissions were obtained; and then, the bark was to be 
administered to prevent the recurrence of the paroxysms, and complete the 
cure. 

For the accomplishment of these ends, the lancet was employed in the 
more violent cases, especially when signs of inflammation in any organ were 
present; and blood was drawn several times in certain cases by some physi- 
cians. Others, however, scarcely employed the lancet in any ; and referring 
to the admitted fact, that the drawn blood was, in most cases, free from buff, 
they argued that venesection could do no good, and might do harm, by 
inducing the typhous state. 

Emetics in those days were standing remedies in this fever. The patient 



INTERIOR VALLEY OF NORTH AMERICA. 99 

generally threw up a liberal quantity of bile, and felt more comfortable after 
the operation. In many cases they were repeated several times. 

Cathartics were in equal, or in e\en greater use, and consisted chiefly of 
calomel and jalap, or of calomel followed by castor oil, Glauber's salt (sul- 
jphate of soda), or an infusion of senna sweetened with manna. A close in- 
spection of the discharges from the stomach and bowels was regarded as 
an indispensable duty at every visit ) and the slightest indication of a return 
to a healthier state of the secretions, was seen with hope and satisfaction. 

Tartarized antimony, generally used as an emetic, and often combined with 
a cathartic medicine, was also administered in nauseating doses ; sometimes 
in simple solution, but oftener in combination with saline refrigerants, of 
which the most reliable were the nitrate of potash, and the acetate of potash, 
or common saline mixture, formed with sub-carbonate of potash and diluted 
vinegar, sometimes administered in a state of effervescence. The spirit of 
nitrous ether was likewise in universal use, and often added to the saline 
draught. But, Professor Rush, who controlled the medical mind of the 
whole country more than any other physician has since controlled it, proposed 
the following receipt, which was almost universally adopted : — 

R.— Nitrate of Potash, £j. 

Tartarized Antimony, - - - - - gr. i. 

Calomel, ----- _._ g rs . v j. 
Triturate together, and divide into six papers. 

One of these powders was given every two hours, through the hot stage. 
They always nauseated, and sometimes produced both vomiting and purging, 
while the nitre acted as a refrigerant and sedative. 

If the calomel thus or otherwise administered, affected the mouth, no re- 
gret was felt by the physician, for, in fact, a mercurial action was thought 
to be curative. It was generally held, that calomel, on the whole, was the 
most important remedy, inasmuch as it would act on the liver (assumed to 
be the organ primarily affected), and at the same time arrest the fever, by 
its influence on the constitution. With these satisfactory reasons for its 
administration, it was generally continued for such a length of time, that 
but few patients got through an attack of the Fever without a salivation. 

Opium, in connexion with sudorifics, was in general use, and after free 
evacuation from the bowels, through the afternoon and evening, Dover's 
powder, or the spiritus Mindereri with paregoric, was administered to pro- 
duce sleep and diaphoresis through the night. 

Cupping was seldom practised, and leeching nearly unknown. But 
instead of these, blisters were employed, not only to relieve local inflamma- 
tion, but to subdue the Fever, when no sign of inflammation existed ; and, 
hence, almost every patient had a blistered surface on some part of his body, 
throughout the whole period of his confinement. 

The object of all this treatment, was to prepare the system for the recep- 



100 THE PRINCIPAL DISEASES OP THE 

tion of the bark and other tonics. The length of time required to effect 
what was regarded as the necessary preparation, varied in different cases, 
but was scarcely ever less than a weela. In many respects this method was 
judicious; and, although I have spoken in the past tense, it still maintains 
itself (with some modifications), in the confidence of a large portion of our 
physicians. 

II. Advantages and Disadvantages of this Treatment. — The 
indications proposed to be fulfilled by this treatment, were, in the main, 
correct ; but some received too much, others too little attention, and a part 
of the means employed acted violently on the system, without superseding 
the morbid action. 

Those who regarded the Fever as arising independently of inflammation, 
often omitted bloodletting; when, even in the absence of inflammation, 
there were reasons for employing it ; and, on the other hand, they who held 
to the inflammatory origin of the Fever, placed too much reliance on that 
remedy. The true reason for resorting to the lancet was not perceived; but 
on this point I shall speak presently. 

The exhibition of powerful emetics and cathartics, before resorting to the 
lancet, was wrong, for they would not operate kindly, and their daily repe- 
tition sometimes produced gastro-enteritis. The signs for their discontinu- 
ance, were a healthier aspect of the tongue, and of the alvine discharges ; 
but, how could they assume a natural appearance, under the daily irritation 
of drastic medicines ? Too much stress was, in fact, laid upon the indica- 
tion — " to correct the state of the secretions." Moreover, many physicians 
prescribed purging for the purpose of lowering the excitement of the vas- 
cular system, when venesection would have accomplished that object much 
better, and without the risk of exciting mucous irritation in the stomach 
and bowels. 

As calomel is, perhaps, the most efficacious of all antiphlogistic alterants, 
and, as the liver seemed to be more involved than any other organ, it was 
not strange, that physicians should have assumed, that a mercurial action 
would supersede the Fever ; and, therefore, should have administered that 
medicine both liberally and perseveringly. The curative results of this 
practice were seldom satisfactory, however; while its pernicious effects 
were sometimes of the saddest character. 

The extensive blistering which made a part of that treatment, was every 
way objectionable. It was sometimes resorted to, while the arterial excite- 
ment was high, when all the effects obtained, were an increase of that 
excitement ; and an extensively ulcerated surface, which added to the suf- 
ferings of the patient, and occasionally became gangrenous. 

Lastly, the administration of the bark was deferred too long ; though, 
we must admit, that it cannot be safely administered, at as early a period 
of the Fever, as the sulphate of quinino 

We come now to speak of curative plans, carved, as it were, out of that 



INTERIOR VALLEY OF NORTH AMERICA. 101 

which has been discussed. Methods founded respectively, on a single idea; 
and therefore, commended to us by their simplicity. 

III. Treatment as for Gastro-enteritis. — The fascinating simpli- 
fications of Broussais, could not fail to meet with advocates among us ; but 
they have never amounted to more than a respectable minority. The assump- 
tion, that remittent autumnal fever is but a primary gastro-enteritis, had 
the appearance of a pathological discovery ; and the proposed treatment 
was acceptable to all, both physicians and patients, who had become tired 
of the polypharmacy, and the uncertain results, of the prevailing method. 
To withhold emetics and cathartics, opium, stimulants, and food ; to give de- 
mulcent and acidulated drinks ; to use the lancet in some cases, and cup or 
leech the epigastrium in all, was at once easy in practice, and captivating 
in promise. In cases which were, really, attended with mucous inflamma- 
tion, this method was beneficial ; and its adoption by a number of our 
physicians, exerted a salutary influence on the rest, by restraining them 
from the excessive administration of tartar emetic, calomel, and drastic 
cathartics. Without having, therefore, superseded, it has modified the older 
method. Two or three things have, perhaps, contributed to limit its more 
general adoption. First. The extreme difficulty of adequate, topical bleed- 
ing, in the country, to which most cases of the Fever belong. Second. The 
desire of our people for strong measures. Third. The general propensity 
in our physicians to employ them ; that is, to be doing a great deal. 

IV. The Purging Practice. — At all times, and with all our physicians 
(except those who adopted the opinions of Broussais), purging, as we 
have seen, has been an important part of our methodus medendi ; but it re- 
quired a peculiar hypothesis, to resolve the whole treatment into that ope- 
ration. This was at length supplied, in congestion of the portal circle and 
the vena cava ascendens. The removal of this congestion constituted the 
sole indication of cure, and was to be accomplished, by increasing secretion 
from the liver and the mucous membrane of the stomach and bowels. Those 
who adopted this hypothesis, as simple as the gastro-enteritis of the French 
school (but suggesting, in the opinion of its advocates, a totally different 
practice), built their hopes on drastic purging, and consistently, made calo- 
mel the governing article of their prescriptions. Thus the mercurial and 
cathartic treatment became united into one method, which in its application 
substituted for the discriminating skill of the physician, the relentless punc- 
tuality of the apothecary and the nurse. Calomel, in doses which the world 
had not hitherto known, was given to excite the liver and mucous mem- 
brane into increased secretion, and drastics, in corresponding doses, to drain 
the bowels, as fast those fluids were poured into them. The object was 
not to supersede the febrile action, by a mercurial irritation of the general 
system ; but to rouse the liver and gastro-enteric membrane into secretory 
excitement j and thus transform the blood of the portal viscera into bile and 
liquor-intestinalis. To this end, scruple doses of calomel were regarded as 



102 THE PRINCIPAL DISEASES OF THE 

sufficient for the mildest cases only ; and drachm doses, at short intervals be- 
came a familiar prescription, in ordinary epidemics ; while, in those of greater 
violence, portions of half an ounce, an ounce, or an ounce and a half, were 
swallowed by the patient several times a day; till in some instances, a pound 
or a pound and a half was administered to a single patient, and gave to his 
excretions the appearance of chalk ! I am not at liberty to doubt the testi- 
mony collected in the South, on which I make this statement. In the State 
of Mississippi, a physician assured me that he had given a patient, one 
thousand grains for three successive days ! As the purgative effects of ca- 
lomel do not increase with the dose, and yet purging was an essential part 
of the cure, medicines better calculated to excite it, were either alternated 
or combined with the calomel ; and these were very commonly given in vast 
doses. A respectable planter in the same state, assured me that he had 
given, by order of his physician, such quantities as I thought incredible; 
till I met with a neighboring physician, who declared that he had adminis- 
tered, in a single case, six hundred grains of a triple compound of aloes, 
rhubarb, and calomel in equal quantities, for six consecutive days ! Such 
instances, I am happy to think, embrace the extreme abuses of this method ; 
and the number who reached these criminal limits, was perhaps not very 
great. It cannot be denied, however, that the practice, here reprobated, was 
for several years that on which numerous physicians of the West and South 
rested their hopes ; and although in general they stopped short of the reck- 
lessness of a few, they carried their single idea to an excess, which at length 
produced a revulsion in the public mind, and in numerous instances led to 
their being superseded by empirics, who declaimed equally against the judi- 
cious and headlong administration of calomel. Under this reaction, it be- 
came at last difficult to exhibit that medicine in any dose, and the blue pill 
is now often substituted, when calomel would be preferable. 

It does not appear, I think, that the immense doses of calomel, adminis- 
tered by a few fanatics, did any more injury, than the drachm doses of the 
majority of physicians. These doses often passed through the bowels un- 
dissolved, and inactive. They did not salivate or purge more than the smaller 
portions. They were, however, a revolting absurdity. The drastic purging to 
which the patients, day after day, were subjected, was no doubt as pernicious, 
though not so frightful to the people, as the mercurial ravages, which in 
many instances accompanied this practice. The former were invisible, the 
latter visible, to the public eye. That the purging practice was often con- 
traindicated by, or produced inflammation of, the mucous membrane, no 
sound pathologist can doubt ; and therein consists one of the weightiest 
objections to the practice. Another is, that in cases which had any latent 
tendency to those paroxysms of collapse, which are called malignant or con- 
gestive, excessive purging soon developed it, so that it has grown into a 
saying in many parts of the South, that congestive fevers are made by this 
practice. Further north, the same purging, has often led to the production 



INTERIOR VALLEY OF NORTH AMERICA. 103 

of a typhous state, equally, though not so immediately dangerous. Finally, 
both this and the practice of the Broussais school, are liable to the grave 
objection, that they aspired to be curative, when, in their most judicious 
application, they were but preparative. 

Having given this brief narrative of the methods of treatment, which 
have prevailed, and indeed still prevail among us, I proceed to speak of 
that to which public opinion has for some years been tending, and which 
seems to me preferable to any which has yet been followed. 

V. Tendency at the Present Time. — Both the methods of treatment 
we have just discussed, are modifications of the first, and that which we are 
now to study, can claim nothing more. Its fundamental principles are, that 
autumnal fever is the product of a specific cause, and, therefore, consists 
in a morbid action of a peculiar kind, requiring a specific remedy ; that we 
possess such an antidote for the intermittent variety of the Fever ; and, 
that, we have only to abate all the causes and points of difference between 
the two varieties, to render the sulphate of quinine as efficacious in one as 
the other. 

But what are the pathological differences between them ? The answer 
must be, that we do not find them, in the functional disturbances and morbid 
secretions of the liver and primse vise, which are generally as great in the 
intermittent as the remittent type. They seem to me to consist in a higher 
febrile excitement of the whole system j a greater tendency to visceral hy- 
peraemias and inflammations; a much longer hot stage; and the consequent 
want of a complete intermission. These conditions being obviated, the anti- 
dote will take effect, as in an ordinary intermittent. The old treatment, it 
is true, proposed all this ; but the change in the condition of the system 
was to be accomplished gradually ; and as each exacerbation of the Fever, 
added to the lesions of innervation, or renewed the inflammation of some 
organ, it often happened, that a suitable condition for the administration of 
the antidote was never reached. 

The new modification of treatment, consists in transforming a remittent 
into an intermittent in a single day, and by a siDgle agent. As stimulation 
will raise an intermittent into a remittent, so an opposite treatment may 
suddenly change the latter into the former j or, at least, so reduce the ex- 
citement of the heart and arteries, that the pathological state of the patient 
is an equivalent for the apyrexia of an intermittent. 

Bloodletting is the means for accomplishing this end. To be successful, 
however, it must be employed in the first, second, or third paroxysm, that 
is, before inflammation in any organ has become established. The quantity 
taken, must be such as will bring the patient to the verge of syncope. 
Pallor and perspiration of the face, yawning, nausea, and a feeble, empty, 
and rapid pulse, must declare, that the excessive excitement of the system 
is, for the time being, effectually brought down. If these effects be not 



104 THE PRINCIPAL DISEASES OF THE 

produced, the preparation of the system for the antiperiodic is not accom- 
plished. 

After such a bleeding, we may or may not administer an evacuant; but 
if decided on, it should be given without delay. In the higher latitudes, 
ten grains of calomel, ten of jalap, and one of tartar emetic, mixed, or a 
solution of the last, with sulphate of magnesia, may be administered. To 
the south, two or four grains of ipecac may be combined with ten or fifteen 
of calomel, and, in a few hours, worked off with castor oil, and oil of tur- 
pentine, mixed, or an infusion of senna and manna. By the sudden and 
profuse evacuation thus effected, the condition of the system, produced by 
the bleeding, will be augmented, and the primae vide prepared for the recep- 
tion of the antidote. But if the signs of gastric and biliary disorder should 
not be great — if the stomach has not been previously irritable, nor the 
bowels obstinately costive, nor the eyes and skin tinged with bile — the 
cathartic may be omitted. 

Having thus lessened the volume of blood, reduced the power of the 
heart, and increased the susceptibility of the system ; having, in other words, 
brought about a transient, artificial intermission, the sulphate of quinine, as 
the specific alterant, must be immediately and liberally administered. If it 
be deferred, another paroxysm will form ; just as we see the fever in scar- 
latina or small-pox return, after bleeding, even to deliauium animi. Those 
diseases, respectively, depending on specific causes, will not yield to a sim- 
ple antiphlogistic treatment ; in like manner, the Fever we are now studying 
depends on a specific cause, and demands for its cure something that can 
supersede the morbid action. To this end, ten grains of the sulphate of 
quinine, with one or two of opium ; and, if no calomel have been given, ten 
grains of that medicine, should be exhibited in a single dose. The results 
which may be expected are sleep and perspiration, with a full, slow, and 
soft pulse. In the latter part of the following night, the dose of quinine 
must be repeated, with or without the other medicines, and again repeated 
about noon the next day. It does not follow that the patient will not, at 
that time, have some degree of thirst, pain in the head or back, and increase 
of pulse ; but his warm perspiration will continue. In this exacerbation, 
an injection may be administered, if he had not been previously purged, or 
he may be bled again. At bed-time, a fourth dose of the quinine, with an 
equal quantity of Dover's powder, should be taken, and another portion of 
quinine should be exhibited early the next morning. If he had not been 
freely purged at the beginning, he may now take a stimulating cathartic; but, 
if possible, should use the pan, and not leave his bed during the operation. 
In the early part of the following night, he must repeat the quinine and 
Dover's powder, after which a repetition will scarcely be required. He 
ought, however, to keep in bed for two or three days longer; a gentle dia- 
phoresis should be kept up, and the healthy action of the liver restored, by 
small doses of the blue pill and quinine, with a gentle opiate at night. 



INTERIOR VALLEY OF NORTH AMERICA. 105 

In principle, this method is the same which we find successful in pneu- 
monia, hepatitis, and some other phleginasise, except that the alterant used 
is different. In pneumonia we do many things, but the detraction of a great 
quantity of blood, followed by the immediate administration of large doses 
of tartar emetic, will effect a cure; in acute hepatitis a similar bleeding, 
succeeded by full doses of calomel, will bring out the desired result. The 
same is true of acute peritonitis, which, readily yielding to these measures, 
proves fatal without them, notwithstanding many other things may be done. 
In these phlogistic fevers, tartar emetic and calomel, respectively, exert an 
alterant influence, which, without the previous bleeding, they could not. 
They have power over common phlegmasia! fever and inflammation ; but 
not over the specific fever, and its associated inflammations; which constitute 
the disease we are now studying. To supersede them, we must establish in 
the system (rendered unresisting by the loss of blood), an action incompa- 
tible with the febrile and inflammatory — a transient quinine disease, which, 
ceasing spontaneously, leaves the patient free from his original disorder. 

But this happy result is not always attainable, and we must now consider 
the causes of failure. I have limited the commencement of the proposed 
treatment to the third paroxysm ; but there may be cases in which it will 
succeed, if begun in the fourth or fifth ; nevertheless, the earlier, the better; 
for, if inflammation have become established in any organ, it may not yield 
to bloodletting, the quinine, or any other means. Moreover, the longer the 
fever has continued, the less is the quantity of blood which can be taken 
away with impunity. The vital energies have begun to fail ; the suscepti- 
bilities have become more perverted, and the blood has fallen into a vitiated 
condition. Under these circumstances, if a free bleeding should be prac- 
ticed, a dangerous constitutional irritation may follow ; for copious venesec- 
tion renders the heart and arterial system irritable; and thus gives to the 
deteriorated blood, a reactive influence upon them, which, before the opera- 
tion, it could not exert. The practice of bleeding to relieve inflammation, 
in an advanced stage of the Fever, has been condemned, even by those who 
bleed freely in the beginning. But may not an immediate exhibition of 
quinine obviate the objection to such a bleeding ? May not that medicine, 
even, contribute to the cure of the inflammation ? Is not the inflammation as 
much a part of the Fever, as the pustule is of variola, a quinsy of scarlatina, 
or the abscess of a lymphatic ganglion, of the chronic fever, present in some 
cases of scrofula? These questions must be answered, I think, in the 
affirmative; and, if so, we might expect advantages from the quinine in 
remittent fever, even when inflammation exists. If, however, it should not 
possess a power of that kind, it would not, I suppose, increase the inflamma- 
tion ; while its peculiar sedative and semi-narcotic operation, would aid in 
repressing the constitutional irritation, which might follow bleeding in the 
stage of the Fever, we are now considering. 



106 THE PRINCIPAL DISEASES OF THE 

Although inflammation is not the cause, but arises with, or supervenes 
upon, remittent fever, still, it is not on that account the less dangerous. 
When it begins with fever, it generally yields to a copious bleeding, and 
the subsequent use of quinine j but when its development is late, it often 
sets our utmost efforts at defiance. Among the means which may be em- 
ployed for its abatement, there are three external applications, in which 
considerable confidence may be placed : First. Long-continued tepid ablu- 
tions and fomentations over the affected organ. Second. Repeated topical 
bleeding. Tfrird. Blistering, which, however useless when there is no in- 
flammation, is of much value when that condition exists. There are, more- 
over, several medicines, which may be employed with advantage. Thus, if 
the inflammation be seated in the liver or spleen, calomel should be admi- 
nistered in doses of four or six grains, every two or four hours, according 
to the violence of the symptoms ; if seated in the mucous membrane of 
the stomach and duodenum, the same medicine, triturated with gum arabic, 
refined sugar, and opium, or the sulphate of morphine, should be employed ; 
if the lungs be the seat of the inflammation, tartarized antimony, and other 
sedative expectorants may be used ; if the brain, calomel with cathartics, 
will be proper. 

Should any one of these inflammations become intense, the fever may as- 
sume a continued type ; when quinine would, perhaps, prove useless ; but, 
if remissions still manifest themselves, that medicine should be mingled or 
alternated, with the other means which have been recommended. 

VI. Facts bearing favorably on the early exhibition of 
Quinine. — The treatment recommended under the last head, is one which 
I have pursued, as occasional opportunities offered, since the year 1838 or 
1839. The effects have been highly encouraging, but I am not under the 
necessity of commending it on such limited grounds, for in several long 
journeys, from 1840 to 1844, I collected the experience of a multitude of 
physicians, from the Gulf of Mexico to Lake Superior, and will present 
an abstract of that portion which is in favor of the early administration of 
quinine. 

At Milwaukie, N. L. 43°, remittent fever is almost unknown; but Doctor 
Hewet, had treated cases successfully on the old method of venesection (in 
some cases), emetics, cathartics, and diaphoretics, for a week, when he ad- 
ministered the sulphate of quinine. 

The Fever is somewhat more prevalent at Racine, a little further south ; 
the treatment, as I learned from Doctor Blanchard, and Doctor Graves, the 
same as that just mentioned. 

Chicago, still further south, on the same western coast of Lake Michigan, 

is far more infested with the Fever. Its treatment, as stated by Doctor 

Brainard, Doctor Brinckerhoff, and Doctor Kimberly, is substantially the 

same as at the two other towns. 

At Port Huron, N. L. 43°, the Fever is frequently epidemic. Doctor 



INTERIOR VALLEY OF NORTH AMERICA. 107 

Noble informed me that he seldom bleeds ; but after the operation of an 
emetic or mercurial cathartic, administers Dover's powder and camphor, till 
an intermission with perspiration is obtained, when he resorts to quinine. 

At Detroit, Doctor Potter regards bloodletting as a most important remedy. 
Doctor Pitcher, a gentleman of ripe experience, resorts to the lancet early, 
gives a cathartic of calomel, and then administers quinine, in five or ten 
grain doses. 

Doctor Denton, of Ann Arbor, west of Detroit, is a strong advocate for 
bloodletting; to which he resorts in the cold stage, rather than the hot, and 
sometimes bleeds twice in one paroxysm ; but does not administer quinine, 
till after a lapse of six or seven days. 

Doctor Landon, of 3Ionroe, south of Detroit, has bled freely, and saw the 
blood sizy ; then purged copiously, and proceeded to the administration of 
quinine j which he has often given with success, when the tongue was still 
heavily coated. 

The estuary of the Maumee, at the southwest angle of Lake Erie, is in- 
fested ith this fever. Doctor St. Clair bleeds freely, and has often seen 
the blood sizy ; uses emetics, and cathartics ; but does not begin to employ 
the quinine for several days afterward. 

Doctor Peck bleeds, vomits with tartar emetic, and purges with calomel 
and other cathartics, till an intermission is obtained. In this condition, when 
the tongue has become clean, and the patient seemed convalescent, the next 
paroxysm has set in with coma, and that which followed proved fatal. In 
other cases, this sinister effect has been averted by five grain doses of quinine, 
in conjunction with the same quantity of calomel. 

Doctor Dwight has in some autumns, bled freely, and seen the blood buffy, 
purged with calomel, and then administered quinine. 

Doctor Van Every, in the autumn of 1838, bled in almost every case, 
sometimes to twenty ounces — after which, cathartic medicines operated 
freely, when he gave three grains of quinine every two hours. 

Doctors Smith and Perkins did not bleed very often, but found the early 
use of quinine, in two-grain doses, every two hours, successful. 

In the same fever, Doctor Ackly gave the blue mass, of calomel with 
morphine and ipecac, or tartar emetic every three or four hours, till a dia- 
phoresis occurred; when Le administered a cathartic, and then resorted to 
quinine. All these observations were made in the same region. 

Doctor Cochran of Sandusky City, south side of Lake Erie, has bled 
freely, given a few large doses of calomel, and then administered ten grains 
of quinine every eight hours, till perspiration came on. 

Doctor Tilden, of the same city, has seen bleeding, vomiting, and purg- 
ing, do harm, when'not followed by an early administration of quinine. 

At Norwalk, near Sandusky, Doctors Baker and Kitteridge, have bled, in 
some cases several times, and found the blood sizy ; administered calomel 
freely, purged with extract scammony and colocynth, followed with castor 



108 THE PRINCIPAL DISEASES OF THE 

oil, and as soon as the remissions were made a little more perfect, adminis- 
tered quinine. 

Doctors Manter and Howard, of Elyria, on the same lake-terrace with 
Norwalk, have found quinine injurious in the Fever, before it was brought, 
by one or more bleedings, to an intermittent type. Have often seen the 
blood sizy. 

Doctor Wallace of Massillon, Ohio, bleeds freely, once or twice, and, 
without waiting for an intermission, proceeds to give quinine in five-grain 



At Joliet, on the Illinois River, Doctor Scholfield informed me that he 
was in the habit of giving his patient from twenty to forty grains of calo- 
mel, with half a grain of sulphate of morphine, while in the exacerbation, 
and followed it the next day with castor oil or salts, immediately after which 
he administered the quinine. 

Doctor Howland, of Ottawa, on the same river, bleeds, and if the patient 
have been costive, gives a cathartic of blue pill and rhubarb; otherwise he 
proceeds at once to administer quinine. 

Doctor "Whitehead, of Lasalle, on the same river, in an epidemic remittent, 
omitted bleeding, administered a dose of calomel and pulvis antimonialis, as 
a cathartic, and then gave quinine in two or three grain doses, sometimes 
combined with Dover's powder, every two or three hours. It arrested the 
hot stage, and brought on perspiration, with a slow and full pulse. 

In Springfield, the capital of Illinois, I found Doctors Todd, Henry, Jayne, 
Merriman, and Frazier, concurring in the practice of very moderate prepara- 
tory evacuation, either from the bloodvessels, or the bowels, and an early 
administration of quinine and opium. 

At Jefferson City, on the Missouri River, Doctors Abbott and Edwards, in 
the declining stage of the first paroxysm, without any previous preparation 
of the system, begin the administration of quinine in two or three grain 
doses, at short intervals, till the paroxysms cease to recur, when they give a 
mild cathartic. When the fever is strongly remittent, they bleed before 
using the quinine. 

Doctor Price, of Arrow Rock, further up the Missouri River, is accustomed 
to resort to quinine after the operation of a single cathartic or emetico-cathar- 
tic, notwithstanding there may be head or back ache. 

Doctor Vaughan, of Dover, near the same river, does not often use the 
lancet, nor administer evacuants, but begins the treatment with quinine and 
calomel. 

Doctors Shanks and Frazier, of Memphis, Tennessee, are accustomed to 
employ the lancet, cold to the head, some small doses of calomel and ipecac, 
and then, at an early period, to complete the cure with quinine. Doctor 
Christian, of the same city, in latter years, bleeds once, gives a few doses of 
spirit of nitrous ether, and then the quinine ; in six or eight hours, a gentle ca- 
thartic, and quinine again ; which method cures in one-third the time of that 



INTERIOR VALLEY OF NORTH AMERICA. 109 

which he formerly pursued. Doctor Grant, of the same city, formerly of the 
hill country, in Alabama, while there, bled freely, cupped, blistered when 
the stomach was irritable, gave a full dose of calomel, and in the first re- 
mission afterward, gave twenty grains of quinine in a solution of tartaric 
acid. A slow and full pulse, with perspiration, followed. 

Doctor Hicks, of Vicksburg, Mississippi, after one bleeding, and a dose 
of calomel, or blue pill, with ipecac, administers quinine with happy results. 

Doctor Gist, and Doctor Cabannis, of Jackson, Mississippi, purge mode- 
rately, in most cases with castor oil, and, in the first remission, give quinine, 
which they think tends to promote intermissions. In some cases they bleed. 

Doctor B. Yandell, of Benton, Mississippi, often employs the lancet, and 
begins the exhibition of quinine before the end of the paroxysm. 

Doctor Davis, of Natchez, bleeds, and resorts almost immediately to that 
medicine. It abates the thirst, and the force and frequency of the pulse, 
increases its fulness, and promotes perspiration. In the cases in which it 
fails to produce these effects, he throws it aside. Doctor Jones, of the same 
city, seldom bleeds, but after the operation of a dose of calomel, or blue 
mass, followed by castor oil, proceeds to administer the quinine, in five- 
grain doses, every three or four hours. 

Doctors Tate, Estes, and Winter, of Columbus, Mississippi, have found 
that many cases of remittent fever, treated only with aperients, and cold 
acidulated drinks, assume an intermittent type, and are cured with the qui- 
nine. These physicians, with their brethren, Doctors Smith, Jones, Lips- 
comb, and the Malones, have found the lancet unnecessary, or injurious, 
and drastic purgatives still more so. After gentle alvine evacuations, they 
depend on quinine. 

Doctors Beall, McCune, and Wilkins, of Pickensville, Alabama, on the 
Tombeckbee Biver, below Columbus, condemn free purging, and do not 
employ the lancet, without following it immediately with quinine. 

Doctor Drish, of Tuscaloosa, in the same state, frequently bleeds, some- 
times vomits, purges with calomel, or the blue mass, combined with opium, 
and then gives one or two grains of quinine, with piperine or morphine, 
every hourm' two. He has seen large doses of calomel produce watery dis- 
charges. 

Doctor Billingslea, on the Tallapoosa Biver, has used large doses of qui- 
nine immediately after bloodletting. 

Doctor Echols, of Selma, bleeds, but generally omits active purging, and 
proceeds to administer quinine. 

Doctor English, of Cahawba, bleeds, cups, administers a mild cathartic, 
and then gives quinine. 

Doctor Hogan, of the same region of country, as his partner, Doctor 
Stone, informed me, stimulates, and administers quinine from the beginning, 
with admirable success. 

When at Natchez, in 1844, I was told by Doctor Cartwright, that Mr. 



110 THE PRINCIPAL DISEASES OP THE 

Charles Crossgrove, a respectable superintendent of a cotton plantation, in 
Concordia Parish, Louisiana, had administered quinine with great success. 
I had a conversation with him on the subject, and, he, also, gave me a writ- 
ten statement, of which the following is the substance : 

On the plantation there are fifty-five negroes, and a white family. No 
physician had been employed for three years. Autumnal fever, in its differ- 
ent varieties, had been the chief disease. He began the administration of 
quinine without any previous evacuation. The first day, he gave two doses, 
of ten grains each ; the next day, three doses, of the same size. He never 
had occasion to administer the medicine beyond the third day, and it had 
never failed, in a single case, to " break the fever." It is worthy of remark, 
that, on the plantations of the South, the treatment is begun with the begin- 
ning of the Fever, before deep-seated congestions or inflammations have been 
formed. 

Finally, I may add, that, when exploring the statistics of the great 
Charity Hospital of New Orleans, in 1844, I found that a change had taken 
place in the method of treating patients there, as great as I have found over 
the country at large. The mercurial and drastic practice had given way to 
mild aperients, occasional bloodletting, and an early exhibition of quinine ; 
the effect of which had been a diminution in the number of deaths, com- 
pared with the number of cases admitted into the hospital. 

These citations show that, in all parts of the Interior Valley, there are 
physicians who, for several years past, have been changing their modes of 
practice in the same direction ; and that, too, without borrowing from one 
another. The reform may be said to have arisen spontaneously in each por- 
tion of the country; and is, therefore, entitled to the greater confidence. 
The facts which I have presented were collected from 1840 to 1844, in- 
clusive, and, at the end of the latter year, transcribed and arranged. During 
that period, and since, more has been published on the treatment of the 
Fever, than for a long time before; and almost every paper testifies to what 
I am attempting to establish. But I do not think it necessary to make a 
transcript of this published experience, as it is within the reach of our phy- 
sicians, and does not materially extend our knowledge on this point, beyond 
the unpublished notes which have just been presented, however strongly it 
may confirm the conclusions to be drawn from them.* 

It may be said that I have given the evidence on one side only. This I 
grant, but I know of none on the other. All our physicians are advocates 
of the quinine-practice ; and even those who postpone the administration of 
the antiperiodic to a later stage of the Fever, and subject their patients to 
a longer preparatory treatment, do not, in general, profess to have given the 

* The papers to which I allude, may be chiefly found in the American Journal of the Medical Sciences, 
and in the Journals of New Orleans, St. Louis, Louisville, Cincinnati, and Buffalo. Several of them are 
from gentlemen whose names are in the foregoing catalogue of authorities. Of those with whom I had 
not the opportunity of conversing, I may mention Dr. McCormick, and Dr. Porter, U.S.A., whose ob- 
servations in Florida,, confirm, in the amplest manner, all that has been said. 



INTERIOR VALLEY OF NORTH AMERICA. Ill 

method here recommended, a trial, and rejected it as injurious or ineffectual. 
They are only more conservative than their brethren — more attached to old 
ways — and yet, even the most cautious among them have abated consider- 
ably in their diversified, and often, perturbating measures. 

VII. Required Modifications of Treatment. — 1. From the Epidemic 
Constitution. — At different times our Valley has been visited by an epidemic 
constitution of the typhous kind. The effect of such an atmospheric influ- 
ence, is to convert our remittent into a continued fever, or at least, to give 
it a set in that direction. This complication of two diatheses, greatly in- 
creases the difficulty of the treatment j for neither the copious detraction of 
blood, nor the liberal exhibition of quinine, is apt to prove beneficial in 
such cases. They are, in fact, exceedingly difficult to manage, and demand 
from us the most careful consideration; but what may be said, can be best 
introduced under the head of typhous fevers ; where the treatment of the 
so-called "typhoid stage" of remittent fever will also be presented. 

2. From a Northern Climate. — In the northern part of the Valley, where 
autumnal remittents often incline to a continued form, quinine is, perhaps, 
not as efficient; and is, certainly, not administered in as large doses as are 
given further south. Copious bleeding would, perhaps, increase the efficacy 
of that medicine in the higher latitudes, while it would, in turn, prevent any 
bad effects from the loss of blood. 

3. From a Southern Climate. — The modification of the proposed treat- 
ment which is required in the South, relates chiefly to the use of the lancet. 
The heat and moisture of the southern climates, in connexion with the 
agent, whatever it may be, which occasions the Fever, so act upon the con- 
stitution, that acute inflammation, and a high phlogistic diathesis, are not 
easily induced; and copious venesection, as a preparative for the quinine, is 
not so necessary as in more northern latitudes. At the same time, that 
medicine seems to act more kindly, and to be borne in larger quantities in 
those climates, than further north ; of which more will be said in the next 
chapter. 



CHAPTER VIII. 

MALIGNANT REMITTENT FEVER. 



SECTION I. 
general remarks. 



The malignant remittent is the most dreaded form of our autumnal fever. 
Malignant intermittents, when left to take their course, will, it is true, ter- 



112 THE PRINCIPAL DISEASES OF THE 

urinate in death; yet they are curable; but, under every known method of 
treatment, malignant remittents often prove fatal. I speak of cases to which 
the alarming epithet is truly applicable ; and not of all which, in the loose 
phraseology of the people, or even of the profession, are called malignant. 
In the middle latitudes they are rare ; and, although more frequent in the 
South, especially below the thirty-third parallel, they are nowhere as common 
as malignant intermittents. In some seasons, and in certain districts of 
country, they are more prevalent than in others. In the year 1843, I 
traversed, on different lines, a zone, extending from Arkansas to Florida, 
which is more infested with this fever than any other portion of the South. 
It lies chiefly between the thirty-first and thirty-third degrees, and includes 
what are called the prairies and canebrakes. The soil of those districts rests 
on cretaceous or "rotten" limestone. As every other form of autumnal 
fever prevails in the same zone, we are required to refer the whole to one 
remote cause ; and confess our ignorance of the subordinate influences which 
generate the diversities which have been described. 

I have conversed with many physicians, who had not recognised a remit- 
ting form of malignant autumnal fever. They spoke only of the inter- 
mitting. Others, however, had observed the distinction, and from them I 
collected facts, which, united with my own observations, give the following 
differential diagnosis. 



SECTION II. 

DIAGNOSIS AND PATHOLOGY. 

I. There is no danger of confounding a case of malignant with one of 
simple or inflammatory remittent fever; for, in the former, certain symp- 
toms which belong to the cold stage, continue in the hot, and even run 
through the remission. 

1. The pulse does not rise in fulness and force during the exacerbation, 
as in the other forms of remitting fever, but remains undeveloped ; being 
generally small, frequent, weak, and more or less variable. But when the 
remission begins, it generally improves in every quality; yet it does not 
become as healthy, as in the remission of a simple or inflammatory case. 

2. The feeling of abdominal oppression, and the anxiety, restlessness, and 
gastric irritability, are deeper in this than in other forms of remittent fever; 
and these symptoms never cease entirely in the remission. 

3. A coldness of the hands and feet, or of the ends of the toes and fingers 
only, continue through the hot stage, while the trunk of the body and the 
head are in high fever heat. With the arrival of the remission this coldness, 
in milder cases, is replaced by a natural temperature ; but, in the more 
malignant, it continues, though, in general, with some abatement. Doctor 



INTERIOR VALLEY OP NORTH AMERICA. 113 

Pickett, of Mississippi, and many other experienced physicians, regard this, 
as the most characteristic sign of the form of fever we are now studying. 

Malignant remittents may be distinguished from malignant intermittents; 
First, by presenting remissions only : Second, by showing less reduction of 
temperature : Third, by the comparative absence of cold sweats : Fourth, 
by more delirium, and less apoplectic drowsiness. With these exceptions, 
the description of malignant intermittents already given, answers very well 
for malignant remittents. In fact, the symptomatical diversity between 
them, is chiefly the difference between intermission and remission — between 
cessation and abatement. Yet, this difference is indicative of pathological 
modifications, which, from their obscurity and danger, demand a rigid in- 
vestigation. In algid intermittents, the feeling of thoracic oppression, the 
dyspnoea, the thirst, and the icy coldness of the limbs, are either followed by 
death in a brief period of time, or they cease, and a comfortable intermission 
follows. In soporose intermittents, the apoplectic stupor ends in death, or 
the patient revives at the end of the paroxysm, and remains free, till the 
recurrence of the next. In both forms, there is such a complete suspension 
of morbid action — such a restoration of healthy function in the internal 
organs — that the patient seems almost free from disease, although the next 
paroxysm may prove fatal. He has neither fever, congestion, nor inflam- 
mation j but there is, in his system, a disposition to fall, again, into the 
pathological state of the preceding day ; and the cure consists in changing 
or destroying this disposition, by the known antiperiodics. 

Xow, in malignant remittents, there is no time when the Fever is absent ; 
and whatever irritations or congestions are formed in the cold stage — what- 
ever inflammations are set up in the hot stage — remain, though moderated 
in degree, throughout the remission. Their continuance is, perhaps, at once 
the reason why intermissions do not take place ; and the cause that this form 
of fever is not as curable as the intermittent. Whenever, in simple remit- 
tents, a complete intermission is effected, the antiperiodic puts an end to the 
disease, as certainly as if it had been, originally, of that type; and we may 
presume, that if a perfect apyrexia could be brought about in malignant re- 
mittents, they would be as easily cured as malignant intermittents. The 
task lies in effecting this transformation — in procuring this absolute inter- 
mission. 

II. To reach a full apprehension of the difficulties in the way of this enter- 
prise, it is necessary to inquire into the pathological conditions, which have 
to be overcome. 

1. In every case there is an original morbid state of the innervation, 
which may be designated by the terms, prostration and irritation ; and 
which, moreover, is peculiar or specific, febrile and periodical. To this 
affection of the solids, much of the feeling of exhaustion, the anxiety, the 
restlessness, and the suspended or morbid state of the secretions, is attri- 
butable. The same condition exists in intermittents, and is doubtless the 






114 THE PRINCIPAL DISEASES OF THE 

chief cause of death, when they prove fatal, without the supervention of 
apoplexy. 

2. To the prostration and irritation of the solids, we must ascribe the 
congestions, which have given a name to the cases we are now considering. 
Our hydraulic, or mechanical pathologists, have too often overlooked this 
antecedent, pathological state, and found nothing to dread or avert, but 
these congestions. They have forgotten, that this unequal distribution of 
the blood, is the effect of an altered condition of the apparatus of circulation ; 
that the greater the congestion, the stronger is the evidence of a deeply 
smitten state of the containing solids ; and, consequently, the greater the 
danger. Still further to narrow down this theory, many of them regard the 
congestion as taking place chiefly in the great vessels, and in the cavities 
of the heart; to these alleged stagnant accumulations of the blood, they 
ascribed the danger. But while we grant that the vena portse, the vena 
cavae, and the right auricle and ventricle, are overcharged and embarrassed, 
we must extend our views beyond them. 

In the fever, now under consideration, the blood, which, before the attack 
was diffused through the whole body, becomes largely accumulated in the 
central parts. The subclavian and external iliac arteries, which, in health, 
receive a large quantity, and carry it far away from the heart, to be slowly 
returned, now receive very little ; and an inordinate quantity takes the course 
of the carotids, and vertebrals, the intercostals, the bronchials, the coronaries, 
the cceliac, the mesenteries, and the emulgents, establishing a central or 
visceral plethora, in which all the cavities of the heart, the arteries, veins, 
and capillaries, participate; by which the whole are oppressed and many 
new symptoms, or aggravations of those previously existing, are produced. I 
do not suppose, however, that the blood continues to circulate equally, and 
freely, through all the organs ; for it is soon discoverable that spnie are more 
oppressed than others ; and they are, of course, the special seats of irrita- 
tion and congestion. 

3. In this pathological condition, the secretions of the liver, stomach, 
and bowels, become highly morbid ; and by their reaction upon the surfaces 
on which they are poured out, increase the very irritations, of which they 
are the products ; thus augmenting the anguish, and the feeling of epi- 
gastric heat, which are such prominent symptoms in every stage of the 
Fever. 

4. Out of the pathological conditions just described, arise inflammations. 
A morbid state of the vital properties of the viscera, in connexion with con- 
gestion, it may be safely affirmed, cannot continue long without origina- 
nating inflammation ; but, we are not compelled to rely on this a priori view, 
for many cases of the Fever are attended with symptoms, which cannot be 
interpreted, except on the theory of inflammation; the unquestionable 
ravages of that local affection, have been found after death. 

"When inflammation is thus added to the previous debility, irritation, 



INTERIOR VALLEY OF NORTH AMERICA. 115 

morbid secretion, and congestion, the complication is complete. Every 
element of difficulty and danger is present; and the concourse of symptoms 
displays, at once, a highly adynamic, and ataxic character. Should any 
one doubt the possibility of inflammation in one organ, while another re- 
mains in a state of passive congestion, and all are prostrated in their vital 
energies, let him contemplate for a moment, the phenomena which follow the 
escape of a portion of the contents of the bowels, into the sack of the peri- 
toneum. Extreme prostration and irritation immediately ensue, and con- 
tinue till the patient expires ; before which event, however, the tenderness 
on pressure, the swelling, pain, and heat, clearly indicate a supervening 
peritonitis. The physician does not doubt its existence, notwithstanding 
the feeble and thready pulse, and resolves on venesection. When only 
four or five ounces of blood have been drawn, however, the patient faints, 
and no rise of the pulse, no reactive impulse of the heart, follow ; yet, the 
blood is sizy, and a post-mortem inspection discloses active hyperemias 
and effusions of coagulating lymph in the peritoneum, with passive conges- 
tions elsewhere. 

Thus it is demonstrated that inflammation may be set up, when the power 
of the heart, and the tone of the arterial system, are in a state of extreme 
reduction ; and, also, that it may continue until death, without arousing them 
into energetic reaction ; which, no doubt, happens in the form of fever we 
are now studying. 

Indeed, great energy in the heart is not necessary to the production of 
inflammation, which, being an affection of the capillary extremities of an 
artery, arises independently of the heart; and may, therefore, be as readily 
established in one condition of that organ as another. But the legitimate 
effect of any inflammation, is to rouse the central organ of the circulation 
into greater activity and stronger impulse. In a common phlegmasia, for 
example, this is done. In ordinary autumnal fever, of the kind denominated 
inflammatory, we observe the same effect ; but, in the malignant variety, 
such a consequence may or may not result from inflammation. Hence comes 
the variety which has been observed in the movements of the heart; some 
physicians having observed them to be essentially feeble, others strong, but 
tumultuous, and inefficient in the propulsion of the blood to distant parts 
of the body. 

In proportion as the inflamed organ is incapable of exciting the heart 
into vigorous, phlogistic action, the case is malignant; and the diathesis, 
which prevents that reactive influence on the central organ of the circulation, 
constitutes the true distinction between malignant and inflammatory remit- 
tents. 

Neither the simple congestion, nor the inflammation which occurs in 
this fever, seems to have any special or invariable seat. There is no fixed 
law of localization, like that which determines the inflammation in variola 
upon the skin, or in scarlatina upon the throat ; yet, as we shall see 



116 THE PRINCIPAL DISEASES OF THE 

hereafter, the abdominal organs suffer more than those of the other great 
cavities. 

It is not likely that inflammation occurs in every case of malignant re- 
mittent 5 and if its ravages were found in all who die, they would only show 
that inflammation was probably the cause of death ; while the patients in 
whom it did not occur, on that very account recovered. 

Of the four pathological conditions — constitutional irritation, simple 
hyperemia, morbid secretion, and inflammatory congestion, the first and 
last are most to be deprecated. When the first is so deep, that the excite- 
ment of the heart will not rise after bloodletting, or under the exciting 
influence of an inflamed organ, the prognosis is bad. On the other hand, 
whenever, from treatment, or the occurrence of inflammation, the heart 
rises in power, and the pulse becomes full and firm, the prognosis is better; 
for however intense the inflammation, it may be subdued or abated by 
treatment. Such a case presents the metamorphosis of a malignant into 
an inflammatory fever. 



SECTION III. 

TREATMENT. 

I. Indications and Difficulties. — No physician enters on the treat- 
ment of a case of our malignant remittent fever, without a feeling of doubt 
as to the means, and of foreboding as to the result. To understand the 
sources of this misgiving, we must recapitulate the points set forth in the 
last section. First. There is a peculiar, original enfeeblement and irritation 
of the vital organs, the first effect of the remote cause. Second. This con- 
dition of the solids, occasions an internal accumulation of the blood, and 
passive congestions of some organ, or organs ; which do not cease, but only 
suffer abatement in the remission. Third. In many cases, some of the con- 
gestions become inflammations. Fourth. Under the influence of one or 
more of these pathological states, the special functions of the organs are 
either suspended or increased, and at the same time perverted. In this 
morbid condition, the sulphate of quinine, as experience has shown, cannot 
exert the specific, alterant, and antiperiodic effect which follows its exhibi- 
tion in the apyrexia of a malignant intermittent; and of course the first 
object should be to bring the system into a state favorable to the action of 
that medicine. The accomplishment of this end has taxed the ingenuity of 
our brethren, in regions where malignant remittents prevail ; but no methods 
of practice have as yet given satisfactory results. 

II. Venesection and Cupping. — When the lancet has been employed, 
the most opposite effects have followed. In some instances the pulse has 
sunk still lower, and the feelings of oppression and anxiety have increased. 
The physician has looked anxiously for reaction, and a more vigorous pulse, 



INTERIOR VALLEY OF NORTH AMERICA. 117 

but none have occurred. In these cases, the primary reduction of the vital 
forces had been great, or the congestions were passive and uninflammatorj. 
A pathognomonic symptom of this condition is certainly desirable; and it 
may, perhaps, be found in the feeble impulse of the heart, discoverable by 
applying the ear or stethoscope to the precordial region. 

But venesection, sometimes, does not produce syncope, but is followed by 
favorable reaction, or open excitement. In these cases, the pulse may be 
empty, feeble, and frequent, yet the heart generally manifests a firm, though 
struggling impulse. When a more open and well-declared excitement fol- 
lows the bleeding, the operation can generally be repeated with advantage, 
in the next exacerbation ; and may even be required in the third, for the 
purpose of moderating reaction — the Fever having been transformed into 
an inflammatory type. 

Cupping or leeching may, of course, be advantageously employed, when 
venesection is inadmissible ; and, as a further means of revulsion, the sur- 
face operated on, should be covered with emollient poultices. There are 
two regions which should be preferred for topical bleeding — the sub-dia- 
phragmatic, and the spinal. A row of cups should be applied from one 
hypochondrium to the other, traversing the epigastric region, where a greater 
number should be placed than to either side. By such cupping, the stomach, 
duodenum, liver, and spleen, the chief seats of abdominal irritation, con- 
gestion, or inflammation, are most effectively reached. Of the extent to 
which the spinal cord is involved in this fever, it is impossible to speak with 
certainty ; but we can hardly doubt that it participates in the irritation and 
congestion (if not inflammation), with which we have to contend. A por- 
tion of the enfeebled and irregular action of the heart depends, perhaps, on 
a morbid condition of this nervous axis ; and a part of the defective circula- 
tion, limited development of caloric, and reduced sensibility of the extremi- 
ties, may be plausibly referred to the same condition. Many of our physi- 
cians, under these, or similar views, have applied cups along the whole length 
of the spinal column ; and the results of the practice have been such as to 
justify its recommendation. 

III. External Stimulation. — Whether venesection or cupping be re- 
sorted to, it is beneficial before commencing, and throughout the operation, 
to immerse the hands and feet of the patient in hot water, rendered stimula- 
ting by mustard, capsicum, or common salt. In cases, moreover, in which 
we doubt the admissibility of bloodletting, it is safe and beneficial, before 
proceeding to the operation, to apply stimulants of a pungent kind over the 
whole spine, the precordial region, or the epigastrium ; surfaces on which 
we can certainly make a strong impression, when it might not be made on 
the extremities. Revulsion, from the internal organs, attends the cutaneous 
hyperemia thus excited; the whole innervation feels the same influences, 
and the loss of a greater quantity of blood can be borne, than might other- 
wise be safe. 






118 THE PRINCIPAL DISEASES OP THE 

In fact, cutaneous stimulation and bloodletting combined, are among our 
most powerful means of exciting reaction. But we too often apply our 
stimulants to parts which are benumbed and nearly insensible; when their 
effects are limited to drawing into the cutaneous capillaries a little of the 
stagnant blood, which still lingers in the muscles below. We see the red- 
ness, and suppose the organism at large must be acted on, when it is not. 
We deceive ourselves by supposing that derivation has been made from the 
affected organs, when it has only been made from the subjacent parts. 

We make hot applications to the extremities, and when their temperature 
is raised with transmitted heat, we illogically and illusively regard the effect 
as identical with restored warmth from developed caloric — thus confounding 
a physical operation with a vital function — and are disappointed if the ex- 
citement of the heart and brain should not rise with the temperature of the 
heated limbs. If the same applications had been made to surfaces where 
the vital forces, the capillary circulation, and the calorific function were but 
little reduced, they would have acted with such energy as to carry an exci- 
ting influence into the central organs of innervation and circulation, when 
the loss of blood would have been better sustained. 

But when no inflammation exists, the internal irritations and congestions 
are often relieved by these powerful revulsives ; which, in fact, make a part 
of the treatment of all our physicians, however they may differ on other 
points of practice. 

If I have not spoken of blisters, it was not because they are useless. 
For the purpose of exciting reaction, they are inferior to sinapisms ; but, as 
means of revulsion, they are greatly to be prized. A large blister to the 
neck, when the brain is the seat of irritation or inflammation, is of much 
service; and, when the stomach and duodenum are specially affected, its 
influence is still greater ; particularly if the surface be afterward covered, 
as I have already suggested, with a soothing, emollient poultice, which will 
promote a mild, suppurative inflammation of the skin, without pain or irri- 
tation. 

And this leads me to say, that when our object in this fever, is not to 
excite the system, but to relieve the abdominal organs, from inflammation 
or severe irritation, it is decidedly advantageous to allay morbid sensibility 
with gentle narcotics, while our sinapisms or blisters are in action. If the 
patient be kept in a state of suffering by the external application — if he be 
restless and irritable — the revulsion will never be as favorable and effective 
as if he be kept composed. And to the administration of an opiate there 
can be no objection, since inflammation is the only prohibiting condition, 
and its grade is too low and irritative, to make it such, in the cases we are 
now considering; or, if it should be otherwise, if the inflammatory action 
should chance to run high, the lancet would prepare the way for the 
anodyne. 

IV. External Emollients. — I have more than once referred to the 



INTERIOR VALLEY OP NORTH AMERICA. 119 

application of poultices to the irritated or inflamed skin. I come now to 
say, that when the brain is the seat of irritation or inflammation, the con- 
tinued application of tepid water to the head, the hair having been shorn, 
is of much value ; and, that for the relief of gastro-duodenal irritations or 
inflammations, it is, perhaps, still more valuable. A stream of tepid water 
cannot be made to fall for an hour on the epigastric and umbilical regions, 
without soothing the organs within. But, as inconveniences may attend 
that mode of application, the whole trunk of the body may be wrapped in a 
dripping-wet sheet, covered with any fabric that will confine the water, and 
thus keep the skin bathed in aqueous vapor of its own temperature. The 
revulsive and soothing effects of such an application are very great. 

V. Vomiting. — As in malignant intermittents, so in the remittents we 
are now considering, antimonial emetics are inadmissible. Indeed, in the 
South, they are a generally admitted cause of the metamorphosis of simple 
into malignant remittents. They prostrate the general system still lower, 
generate gastric irritability, and excite serous diarrhoea. Yet vomiting is 
not always injurious. When the system is sunken and torpid, and passive 
congestions exist, a salt-and-mustard emetic often does good ; but, in cases 
accompanied by, or tending to inflammation of the stomach or duodenum, 
with acrid secretions, the mustard is too stimulating, and the wine of ipecac, 
or a hot infusion of the Eupatorium perfoliatum, or of Lobelia inflata, 
should be chosen. Of the whole, the last is perhaps the best. While 
visiting the states of Alabama and Mississippi, in the year 1843, 1 learned, 
from many reliable persons, both in and out of the profession, that vomiting, 
with that medicine, had been found signally beneficial; and, in 1844, 
Doctor Monette, in a valuable paper on this form of fever,* bore unqualified 
testimony to its efficacy in the following language : — 

" Emetics of the ordinary kind, that is of ipecacuanha or tartrate of anti- 
mony, the latter especially, are unsafe in most cases of congestive fever; 
unless the action and sensibility of the stomach have been previously excited 
by pepper and brandy, or some other pungent aromatic. Without a previous 
use of these precautionary measures, the ipecac or tartar emetic may pros- 
trate without vomiting, or it may possibly pass off by the bowels, and pro- 
duce hypercatharsis instead of emesis as desired. Yet there is a valuable 
article of the emetic class which is, at the same time, stimulant and emetic. 
This is the Lobelia inflata, which excites immediate vomiting, without any 
attendant prostration. 

"This article, when properly used, is one of the most valuable emetics 
and stimulants in the materia medica, for the treatment of congestive fever. 
Its action is prompt, speedy, and easy, in the evacuation of the stomach, 
and in developing excitement. Nothing is more gentle, nothing more safe, 
nothing more salutary. 

" There are cases, wherein it is desirable, after the excitement and reac- 

* New Orleans Medical Journal, Vol. 1, No. III. 



120 THE PRINCIPAL DISEASES OF THE 

tion have been partially restored, to discharge the morbid secretions and 
ingesta, from the stomach, when they have become a source of morbid irri- 
tation. In such cases, to insure the prompt action of the emetic, the patient 
should first take a wine-glass full of warm toddy, with the addition of a few 
grains of capsicum to rouse action and sensibility in the stomach. A few 
minutes having elapsed, a full dose of fifteen or twenty grains of ipecacuanha, 
mixed in a wine-glass full of warm toddy, may be taken with great advan- 
tage. The operation is prompt, and instead of prostrating the patient, it 
excites the general action of the system, and promotes a salutary excitement 
in the stomach itself, and the collatitious viscera. Soon after free emesis 
has taken place, the system and the stomach specially, should be calmed 
and equalized by a gentle anodyne of morphia, or camphorated tincture of 
opium. A teaspoonful, or less, of the strong tincture of the seeds of the 
Lohelia infiata, will often be preferable to the ipecacuanha, as acting more 
promptly, and inducing less tendency to prostration. " 

The advice to administer a narcotic, after the operation of a vomit is 
highly judicious. Among other good effects which it may produce, is that 
of determining to the surface of the body ; and, consequently, of making 
revulsion from the internal organs ; to this end the vomit is an efficacious, 
predisposing remedy ; for, as long as the stomach is oppressed or irritated 
by peccant matters, in any form of disease, perspiration cannot be excited. 
Moreover, vomiting at all times promotes that function. 

VI. Purging. — When congestion, either passive or inflammatory, occurs 
in the brain, cathartics are demanded; but the saline and hydragogue are 
not proper. Pills composed of equal parts of calomel, rhubarb, and com- 
pound extract of colocynth, make one of the best; and the first dose should 
be sufficient to effect a perfect evacuation. Should the cerebral disorder 
continue, the medicine may be repeated ; unless a state of exhaustion should 
follow the first operation. The great object is to make revulsion from the 
brain ; but this method may reduce the vital energies, faster than it diverts 
from the brain ; and still further, it may establish a mucous irritation in the 
stomach and bowels, which in the end may prove dangerous. Notwith- 
standing the great efficacy, then, of purgation in ordinary apoplectic conges- 
tion, and in cerebritis from common causes, there is a narrow limit to its 
utility in the cerebral affections, which sometimes accompany our malignant 
remittents. 

When the topical affections, or localizations of the Fever are found in the 
abdominal organs, a much greater abstinence from active cathartics is re- 
quired. If the patient have been costive, a freer evacuation is necessary ; 
but, even then the operation should not continue after the existing contents 
of the bowels have been removed ; nor should the subsequent administrations 
have anything for their object, but the evacuation from time to time, of 
what may be poured into the bowels from their own mucous membrane, and 
the liver ; the retention of which is always injurious. When diarrhoea is 



INTERIOR VALLEY OF NORTH AMERICA. 121 

present, a moderate cathartic, followed by opium and stimulants, may be 
safe, and productive of a quieter condition of the bowels. In all cases, how- 
ever, hypercatharsis must be avoided as eminently pernicious. 

Great care is necessary in the selection of cathartics, A portion of calo- 
mel — five, ten, or fifteen grains — worked off with a decoction of rhubarb, 
is proper; or the latter may be replaced with two drachms of castor oil, and 
one drachm of oil of turpentine, mixed ; or with a powder of rhubarb and 
magnesia, should the previous discharges have evinced acidity. Another 
method of safe purging, in these cases, is to give pills composed of two 
grains of blue mass, two of rhubarb, and one of ipecac ; which may be 
quickened in their operation by any of the mixtures just mentioned, or by 
the compound tincture of senna. Whatever medicines may be chosen, they 
should not be permitted to operate, on the same day, more than two or three 
times ; and even a single copious evacuation will be sufficient ; the object 
(properly) in view, being the evacuation — not the production — of morbid, 
secretions. 

Such is the present state of medical practice, among the best observers, 
where malignant remittents most prevail ; and it contrasts, strikingly, with 
the practice which it has superseded. Of the pernicious effects of inces- 
sant, and drastic purgation, I have already spoken, under the head of simple 
and inflammatory remittents; which were, sometimes, transformed by it, into 
violent gastro-enteritis; at other times, into still more dangerous malignant 
fevers. The pernicious effects of the practice were, however, incomparably 
greater in the form of fever we are now studying, than in the open inflam- 
matory. Those who pursued the practice, saw in the cases before them 
nothing but an oppressive accumulation of blood in the abdominal organs — 
they had no end in view but its removal — they employed no means but 
those which would convert it into secreted fluids, and then evacuate them 
from the bowels. The certainty of increasing the debility of the patient 
was unheeded ; and the danger of exciting or aggravating irritations and 
inflammations of the stomach and upper bowels, was overlooked. But 
apart from these serious objections to the practice, was it fitted to accom- 
plish the end they had in view ? It certainly was not ; for purging, pro- 
duces an introversion of the blood, the very condition for which it was pre- 
scribed. In the treatment of erysipelas, scarlatina, and other acute inflam- 
mations of the skin, the beneficial influence of cathartic medicine is produced 
by their diverting from the surface. On the same principle, after extensive 
burns or scalds, a favorable suppuration is prevented by purging, which re- 
duces the cutaneous circulation. Finally, the free operation of a cathartic, 
when an individual is in health, never fails to produce a pallor, reduction of 
surface heat, and a shrunken aspect of the superficial parts of the body, show- 
ing a centripetal tendency of the blood ; which of course, accumulates in 
the vessels of the interior. A therapeutic agency which produces such 
effects can never be adapted to the removal of the assumed abdominal con- 



122 THE PRINCIPAL DISEASES OF THE 

gestions, in malignant intermittent fever. The organs, it is true, may be 
depleted by the increased secretion ; but the means employed, and the secre- 
tory actions which they excite, keep up the supplies of blood from the outer 
parts of the body, and thus maintain the congestion for the cure of which 
the drain was established. 

VII. Calomel. — In the last chapter, an estimate was made, of the 
use of calomel in the treatment of simple and inflammatory remittent fever. 

If we found, that too high a value had been placed upon it, in the treat- 
ment of those varieties, and that its liberal administration had often done 
harm ; we may expect to find, that, in the cases we are now studying, it 
has, still oftener, disappointed the expectations of those by whom it has 
been prescribed; for it is unquestionably true, that it acts more kindly and 
efficiently in cases of an inflammatory character (after bloodletting) than in 
the adynamic and ataxic. The suspended, or morbid condition of the se- 
cretions of the liver, in connexion with epigastric tenderness and anxiety, 
so often present in this fever, suggested that calomel could not fail to prove 
salutary beyond every other remedy, and for many years it was administered 
in large quantities, especially in the South j but, in 1843, and 1844, I found 
that this practice had been generally renounced j yet the memory of its 
failures and ravages, had not faded from the minds of the profession, or the 
people. It was exhibited for the fulfilment of various speculative conditions 
as for exciting the liver into increased secretory action, that the portal circle 
might be relieved from congestion ; for subduing gastro-duodenitis, extend- 
ing into that organ, and for allaying simple irritation of the same parts.* 
The greater number had the first of these objects in view, and seemed to 
have lost sight of the fact, that the suspended or morbid action of the liver 
was secondary, and the consequence of a localization of the Fever, in the 
form of irritation or inflammation, upon the hepatic system ; or if they ad- 
mitted the existence of those pathological states, they assumed that calomel 
was the best means of curing them. 

That moderate portions of that medicine, in connexion with other reme- 
dies, are useful, cannot be denied ; but their exclusive and inordinate use 
is greatly to be deprecated. After local bleeding, and the evacuation of the 
existing contents of the primae vise, by the means just pointed out, the ad- 
ministration of three or five grain doses of calomel, in combination with 
small quantities of opium, morphine, or Dover's powder, and a free use of 
slightly acidulated demulcent drinks, with abdominal fomentations, are safe 
and beneficial. But, the epigastric irritation may be allayed, and the biliary 
secretion re-established by other means. Thus, Doctor Monettef declares, 

* Some years before the visits of which I have spoken, a physician of Louisiana, flippantly and hyper- 
bolically wrote me, that in a certain epidemic, he had drawn "blood enough to float, and give calomel 
enough to freight the steamboat General Jackson !" During my first visit, another, who had given it by 
the ounce, said his object was, to load down the irritable stomach, so as to prevent vomiting ! While 
multitudes believed, that when they did not obtain bilious discharges, by ounce doses, it was because 
they were too timid in administration ! 

f New Orleans Journal, loco citato. 



INTERIOR VALLEY OF NORTH AMERICA. 123 

that since be has discontinued the exhibition of calomel his practice has 
been more successful than before. One of his formulae for allaying gastro- 
duodenal irritation, is the following : — 

R. — Sulphate of Magnesia, -.--..- ^ij- 

Ipecac, ------ grs. iii. 

Tincture of Opium, - - - - gi. 

Water, ------ g Y i. — Mix. 

The dose is half an ounce every hour, or every two hours ; according to 
the judgment of the physician in each case. 

" This mixture, continued for twelve or fifteen hours, and sometimes, in 
less time, is followed by an abatement of the gastro-duodenal irritation, a 
general relaxation of the skin, and a full and soft pulse. Besides these salu- 
tary effects, a perseverance in the use of this mixture, for a longer time, 
is followed by a free and gentle discharge of thick yellow bile. During this 
administration, if the intestinal canal be in a high state of irritation from 
previous purgatives, or copious watery discharges, anodyne and emollient 
enemata are not to be neglected, nor demulcent drinks, of which none is 
superior to the mucilage made of the prickly pear by cold infusion. " 

Doctor Monette acknowledges himself indebted to Doctor McPheeters, 
one of the most sagacious practitioners of Mississippi, for a knowledge of 
the efficacy of sulphate of magnesia, in small quantities, with laudanum, in 
the irritations we are now considering. The addition of ipecac, made by 
himself, gives, according to his experience, additional efficacy to the prescrip- 
tion. When there is much developed fever, he adds to the mixture an 
ounce of spirit of nitrous ether. 

" The proportions of each ingredient may be varied to suit peculiarity 
of cases. If the irritation was extreme, the first recipe was used ; and the 
quantity of sulphate of magnesia diminished one half, and the tincture of 
opium increased in the same proportion. If the duodenal irritation was 
moderate, and the bowels appeared irritated with a profuse secretion of acrid 
bile, the quantity of sulphate of magnesia was increased; and sometimes the 
tincture of opium was diminished in the same proportion." 

VIII. Kefrigerants, Sedatives, Cholagogues, Diuretics, and Su- 
dorifics. — I have joined these different heads together, because of their 
relations in practice. As long as the treatment of our malignant remittents 
was confided to unlimited doses of calomel, and unrelenting purgation, 
various means of a gentle character were entirely neglected, as inconvenient 
or incompatible ; yet their adaptation to the form of fever now before us 
cannot, I think, be doubted; especially when the local congestions, irrita- 
tions, and inflammations are seated in the abdominal organs. The con- 
tinued introduction of pellets of ice into the stomach is often productive of 
relief; but they act merely as local coolers, by absorbing their caloric of 
fluidity from the parietes of the organ. Of all refrigerants, I suppose water 



124 THE PRINCIPAL DISEASES OF THE 

to be the greatest ; and am quite convinced that its powers in this, as well as 
many other forms of fever, have not yet been fully tested. After the stomach 
and bowels have been evacuated, if the former should not be irritable, 
water should be drunk in large quantities; and, to give it greater efficacy, 
the system should be brought slightly under the influence of an opiate. As 
a topical application to the irritated or inflamed mucous membrane of the 
alimentary canal, it is one of the most soothing. But passing readily, by 
endosmosis, into the gastric veins, it is carried not only through the liver, 
but the entire organism j diluting the blood and allaying the febrile irrita- 
tion of the solids, abdominal, thoracic, and cranial. Thus it is at once a 
cooler and a soother ; and being one of the sustainers of life, refreshes and 
invigorates, while it allays morbid action. Other effects, however, result 
from its liberal introduction into the bloodvessels. All experience proves 
that the system makes unceasing efforts to keep the amount of water in the 
blood uniform ; and, hence, when the quantity is increased, the secretory 
apparatus is immediately excited into increased action, for the purpose of 
throwing off the superabundance. To what extent the secretion of the liver 
may be promoted by this agency we cannot decide; nor do we know in what 
degree the pulmonary exhalation may be augmented ; but from analogy, 
may presume, that both, and especially the latter, are increased. As to 
the other secretions there can be no doubt, for a flow of urine or of per- 
spiration, according to the circumstances under which the individual is placed, 
invariably occurs. To obtain the former, the nitrate of potash or the spirit 
of nitrous ether, may be administered in appropriate quantities during the 
period of aqueous dilution. The first has long been regarded as a valuable 
refrigerant, and the last has maintained a high rank, as a febrifuge, under 
every modification of the theory of fever ; while both direct the superfluous 
water upon the kidneys, and by increasing their secretion, eliminate from 
the blood, many things developed or thrown into it during the Fever, which 
reactively, keep up the febrile irritation. But the action of the diluent 
upon the skin is still greater than upon the kidneys, if the patient be placed 
under circumstances favorable to perspiration. These are rest, silence, and 
diminished light ; adequate covering ; heat to the extremities, and the ad- 
ministration of gentle narcotics and diaphoretics, such as a hot infusion of 
serpentaria, balm or orange leaves, with small portions of Dover's powder, 
or the following mixture : — 

R. — Spiritus Mindereri, ----- ^viss. 

Spirit of nitrous Ether, - 3ss. 

Camphorated tincture of Opium, - - |jss. 

Wine of Ipecac, - - - - - - % ss. — Mix. 

Half an ounce of this mixture, taken every two hours, will seldom fail to 
bring on perspiration, if the pathological condition of the patient be such as 
to admit of the restoration of that function of the skin. On the value of 



INTERIOR VALLEY OF NORTH AMERICA. 125 

such an effect there can be but one opinion. The centrifugal determination 
of the blood, without which the perspiration cannot be established, of 
course tends to relieve the internal organs from congestion ; the reactive 
influence of an improved state of the skin upon the liver and the mucous 
membrane of the stomach and bowels, must be admitted as a reality; finally, 
the blood is depurated of peccant matters, which often give to the perspired 
fluid an offensive odor; and, retained, irritate the interior of the arteries. 

IX. Sulphate of Quinine. — The various means which have been 
pointed out, have for their object to convert the remittent into an intermit- 
tent : to produce a state of apyrexia, unaccompanied by visceral congestion, 
irritation, or inflammation. In many cases this is slowly accomplished 
each remission becoming more perfect than the last ; but in some the end 
is much sooner attained. When it is reached, the patient, as in the common 
inflammatory form of remittent fever, treated with active antiphlogistics, will 
sometimes recover if left to himself; but this should never be assumed; for, 
on the succeeding day, the paroxysms may return and prove as fatal, as the 
fit of a malignant intermittent. Had this fever been of a continued type, 
from some common cause, such an event could not occur ; but being essen- 
tially periodical, the antiperiodic should, on no account, be now omitted. 
The quinine, which up to this time, when the remission has become more 
perfect, could not have been administered with advantage or even impunity, 
will now begin to establish in the system its peculiar effect ; and the recur- 
rence of the paroxysm will, at length, be precluded. It is not necessary to 
dwell on the mode of administering the quinine in such a case. Before an 
intermission is effected, it must be used in small quantities. But when that 
state is brought about, it may be given in five or ten grain portions, in con- 
nexion with solid opium, and repeated every two or four hours. If great 
exhaustion should be present, it will be requisite to stimulate the patient with 
camphor, ammonia, or tincture of capsicum, wine-whey, wine, or ardent spirit ; 
and, at an early period, to give him a moderate quantity of nourishing diet. 
His feet should be kept warm, and a gentle diaphoresis maintained. Should 
there be a tendency to diarrhoea, which the opium does not arrest, injections 
of starch, and a decoction of Peruvian bark, with laudanum, will be effica- 
cious. If bile do not appear in the evacuations, small doses of blue pill may 
be conjoined with the quinine and opium, or the region of the liver may be 
sponged with a strong nitro-muriatic solution. 

When one day has passed without a recurrence of the paroxysms, the 
patient will probably go on to recovery ; but the quinine must not be discon- 
tinued, for the type may now change from quotidian to tertian ; and, on the 
third day, the fever may return, unless the system be kept under the influ- 
ence of the specific. 

X. Cases and Bemarks from Doctor Ames. — The following condensed 
account of seven fever cases, from Doctor Ames, of Montgomery, Alabama, 
shows that in negroes, at least, a manifest irritation of the brain does not 



126 THE PRINCIPAL DISEASES OF THE 

contraindicate the employment of the sulphate of quinine without previous 
evacuation. The symptoms and treatment were nearly the same in all, and 
all recovered. 

" Tongue slightly coated, ash-colored, yellowish, or natural ; sometimes dry, 
but never hard or fissured. Heat of the trunk and head natural, or a little 
below; legs and arms cool; feet, hands, nose, and ears, cold. Pulse from 
one hundred and twenty to one hundred and forty, small, feeble, and indis- 
tinct. The brain strongly affected — coma and delirium alternating; the 
latter violent when the patient was disturbed; indisposition to speak; aver- 
sion to swallowing with obstinate resistance. The stomach and bowels 
natural, except a little nausea in two or three. Treatment substantially the 
same in all. Blisters to the neck ; mustard to the extremities ; and sulphate 
of quinine in large doses, without regard to the stage of the disease. Conva- 
lescence in the whole begun before the fourth day. " 

Another case affords evidence coincident with this : — 

" A young gentleman aged sixteen, was attacked with a chill, which was 
quickly succeeded by convulsions. His pulse was about eighty beats in a 
minute, nearly as full as in health, but soft and hollow ; he soon became 
comatose, but was sometimes wakeful, and restless ; the temperature of his 
skin was everywhere natural ; his pupils were dilated ; he refused to swallow 
anything but water, and screamed and struggled violently when disturbed ; 
did not speak, or even attempt to articulate. He continued in this state 
about forty-eight hours, during which he was bled to ten ounces, with a bad 
effect. He was repeatedly immersed in a warm bath, having cold applica- 
tions to his head ; he took a cathartic, which operated promptly ; blisters 
were applied to his neck, arms, and thighs. Attempts were made to admi- 
nister quinine ; but, for some time, very little was swallowed ; at length, how- 
ever, he took it regularly and freely, with immediate benefit and complete 
recovery. " 

The following observations, from the same gentleman, present still further 
the results of his experience in the soporose, malignant fever, of the region 
around Montgomery: — 

" The coolness of the surface, in these cases, is never the coldness of col- 
lapse ; nor is there ever the profuse sweating, the diarrhoea, vomiting, epi- 
gastric oppression, sighing, jactitation, and general restlessness, characteristic 
of abdominal, congestive remittents; neither have I, at anytime, observed 
muttering delirium, or picking of the bedclothes ; headache is never spon- 
taneously spoken of after the disease is fully developed, though it is a com- 
mon precursory symptom. The aspect of most of the cases is that of pro- 
found sleep, but without the stertor or pulse of apoplexy. Now and then I 
have seen a case in which the skin was above the natural temperature, with 
throbbing of the carotids, but the pulse had no firmness. In that condition 
the coma is less profound. The refusal to swallow medicine is a character- 
istic of this form of fever. " 



INTERIOR VALLEY OP NORTH AMERICA. 127 

11 Quinine is better borne in congestive remittents and intermittents, than 
in any other form of fever. It is tolerated by the system, as tartar emetic is 
tolerated in pneumonia, and bloodletting in cerebral inflammation. I lately 
gave a negro boy, under twelve years of age, about fifty grains of quinine, 
within twelve hours, without producing deafness or ringing in the ears. 
Its good effects, however, were none the less evident. Bleeding, as far as 
I have seen, even in small quantities, does harm. Blisters and sinapisms 
are valuable adjuncts, particularly the former, and so is the hot foot bath. 
Nothing can be said in favor of purgatives ; though I have occasionally seen 
full vomiting with tartar emetic, produce the best effects. When the pulse, 
under the use of quinine, gets more feeble as it becomes slower, with a 
copious supervening sweat, I know of no remedy equal to carbonate of 
ammonia, the quinine being at the same time suspended. " 



CHAPTER IX. 

PROTRACTED, RELAPSING, AND VERNAL INTERMITTENTS. 



SECTION I. 

CHRONIC AND RELAPSING CASES. 

I. We have already seen, that many facts conspire to prove that all the 
varieties of autumnal fever, depend on one specific, remote cause, and, we 
now come to an additional fact in support of the same conclusion. It is, 
that in many cases, the different forms of remittent fever, at last, assume 
an intermittent type ; and continue to recur, for an indefinite period, in the 
manner of original, nncured intermittents ; from which, in fact, they cannot 
be distinguished. This being the case, I have postponed an account of 
their character and treatment, until all the acute varieties of the Fever, of 
which they are properly the chronic form, should have been studied. 

II. Regular, Chronic Recurrence. — When an intermittent becomes 
chronic, it generally shows a disposition to recur, at more distant intervals. 
A quotidian, it is true, if neglected, may continue as such for several weeks ; 
but such cases are not numerous, and a change to the tertian type is a com- 
mon event. There are, moreover, many original tertians, which become 
chronic. In this form, when not arrested, they may run on for months. 
Sometimes a recurrence on the fourth day, including that of the preceding 
paroxysm, gives us a quartan ; much more rarely, the return is on the fifth 
day, constituting a quintan. A recurrence on the seventh day (septan) is, 
however, common. This is the day on which the third paroxysm of a 



128 THE PRINCIPAL DISEASES OF THE 

tertian, and second of a quartan, would return ; which, perhaps, explains 
the liability to recurrence on that day. But discarding all speculation, I 
may state as a fact, that the hebdomadal period is, pre-eminently, that of 
many protracted intermittent^ ; the recurrence of the paroxysm being, in 
some instances, between the thirteenth or fifteenth, in others the twentieth, 
twenty-first, or twenty-second, and in others the twenty-eighth, twenty-ninth, 
or thirtieth day. Still further, in some instances, after the Fever seems to 
have ceased entirely, it returns at a multiple of this hebdomadal period. 
The following case, from Doctor Raymond, illustrates this point : In the 
autumn, he had three paroxysms of intermittent fever. The next spring it 
returned, and was arrested by an emetic and half a drachm of quinine. In 
twenty-one days it recurred, and continued its visits, at the end of that 
period, until August. He was then bled, after which its recurrences were 
at the end of the fifth, instead of the third hebdomadal period, until De- 
cember, when it was finally stopped by arsenic. 

The causes which render intermittents protracted, deserve consideration. 

1. Of the whole we should, undoubtedly, ascribe the greatest influence to 
the agent which produces the disease. It is of the very nature and essence 
of that agent, to generate an intermittent irritation ; which shall soon pass 
away, but return at the end of twenty-four hours from the beginning of the 
previous fit, or at the end of some multiple of that period. We cannot, I 
apprehend, go further than to recognise the fact. In some constitutions, the 
primary impression wears out much sooner than in others : the latter present 
us with the disease in a chronic form. It is common to say, that the fits 
recur from habit; but habit is custom confirmed ; and the question in these 
cases is, what maintains the custom until it grows into a habit ? One person 
has a habit of waking at a certain hour in the morning; another at a dif- 
ferent hour; in both cases some agent was employed to create the custom; 
but, after a time, that agency may be withheld, and the effect will continue 
from habit. Intermittent fever, then, cannot become chronic from habit; 
but having been made so by the influence of some cause, habit may, at last, 
contribute to reproduce the paroxysms. 

2. The Fever is sometimes kept up by the unabating action of the remote 
cause. Thus, there are many instances of its continuance as long as the 
patient remains in the locality in which it was produced, and of its ceasing 
on his removal to a more salubrious spot. 

3. It is probably rendered chronic, in certain cases, by the permanent 
congestion or subacute inflammation of some organ. 

It is held by many of our people, and, perhaps, by some physicians, that 
if chronic intermittent fever be not interrupted by medicines, but allowed 
to run its course, until it ceases spontaneously, the individual, although 
continuing in the same locality, will, ever after, remain free from an attack. 
His system loses its susceptibility to the poison. A gentleman, in Illinois, 
assured me that this had been the result in his own case ; and that he was 



INTERIOR VALLEY OF NORTH AMERICA. 129 

led to make the experiment, by the assurance of others, that they had, 
by that method, obtained a permanent immunity. The greatest objec- 
tion to such a course is, that some organ may become seriously deranged 
in structure. 

II. Relapses. — Relapsing intermittent fever, is but a variety of chronic. 
The paroxysms cease from the influence of the treatment ; but the tendency 
to recurrence remains, and constitutes a true predisposition. An exciting 
cause is generally necessary to the reproduction of the paroxysm. An in- 
dividual in this condition, is compelled to be circumspect, in regard to what 
the old pathologists called the non-naturals. The loss of a night's sleep, a 
day of protracted fatigue, exposure to cold and moisture, an excessive and 
indigestible meal, or a strong mental emotion of the depressing kind, may 
bring back the disease. In this predisposition, moreover, a cold, saline 
cathartic, often proves an exciting cause, and should be carefully avoided. 
But of all these causes, the exposure which chills the surface of the body. 
is most injurious. Hence it is, that those who have had the Fever in 
August or September, and may have been free from it in October, and the 
mild and dry portions of November, are liable to relapses afterward. These 
may occur uncomplicated with any other affection ; but it frequently happens, 
that the sudden change of weather, which excites an inflammation of the 
lungs or some other organ, reproduces the Fever, so far, at least, as to give 
a paroxysmal character to the phlegmasia, and render great modification 
of its treatment necessary. In addition to the external exciting causes 
which have been enumerated, we ought, perhaps, to recognise an internal 
pathological influence, in the enlarged spleen, which so generally occurs in 
protracted cases. That local affection, it is true, results from the Fever ; 
but it often begins in the first paroxysms ; and the experience of the profes- 
sion is, I think, that, as long as it continues, the patient is more subject 
to relapses than others, in whom that organ is not disordered. Thus it 
seems to maintain the predisposition ; and without being one of the excit- 
ing causes, renders the system still more susceptible to them, than it would 
otherwise be. 



SECTION II. 

VERNAL INTERMITTENTS. 

I. The intermittents which occur in winter, are generally sporadic, and 
this may also be the case in spring. Nevertheless, the Fever often displays 
an epidemic character in the latter season. Whatever may be the number 
of cases in any locality, we are not to conclude, that they are the offspring 
of poison developed in that season, but relapses, like those of winter. 
They are, generally, numerous in proportion to the prevalence of the Fever 
in the preceding autumn ; the subjects are, chiefly, those who have suffered 

VOL. II. 9 






180 THE PRINCIPAL DISEASES OF THE 

at that time ; and the symptoms, and most successful treatment, mark 
them as relapses, instead of attacks from a new application of the remote 
cause. It would appear, that the steady cold of winter, is much less in- 
jurious, than the diurnal and occasional vicissitudes of February and March, 
in the South — of March and April, in the middle latitudes — and of April 
and May in the northern. After the hot weather has set in, they commonly 
cease ; and this is the termination of the epidemic of the preceding year ; 
which, beginning in the last month of summer, ends in the last month of 
spring. The Fever of the next autumn, depends on a new development 
and application of the remote cause; to the action of which, however, those 
who suffered the year before, are, very commonly, as liable, as those who 
might not have resided in the locality at that time, and, in many instances, 
more so. 

The exciting causes of winter relapses, are equally productive of the 
vernal ; and one of them — undue and chilling exposure of the surface of the 
body — is far more general ; from the imprudent and premature disuse of 
flannel, and of winter clothing, upon the access of warm weather. Those 
who are obnoxious to the Fever, should therefore wear their flannel, till the 
hot weather is established, or even throughout the summer; and should 
carefuly avoid exposure to the stormy weather of the equinox, or the sudden 
showers of April, both of which are more injurious than the snows and 
northwest winds of winter. 

It is a popular opinion, that standing or sitting in the sun, in spring, will 
bring on a relapse ; but this I apprehend, is an example of false observation 
— the transposition of cause and effect. Those who are relapsing, find 
such exposure pleasant j a full development of the disease follows, and is 
fallaciously ascribed to the influence of the sun's rays. 

The relapses which occur late in spring, are apt to present more of gastric 
and biliary derangement, than those which happen early. This results 
from the impress of heat, and the same cause, gives to the hot stage of 
the paroxysm, more intensity than it displays at any earlier period. These 
facts have led to the opinion, that the special, remote cause is generated de 
novo, at that time ; but I see no reason for the supposition. 

As a general fact, vernal intermittents are not violent nor dangerous, but 
there are exceptions ; and the following observation, communicated to me by 
Doctor France, is one of the evidences. In Powell's Valley, Virginia, inter- 
mittent fever was epidemic in the autumn of 1843. January was cold, 
but early in February, the weather became so warm as to give an impulse to 
vegetation ; during which the Fever reappeared in a great number of per- 
sons, and, in many, assumed a malignant character. 

II. Deferred Attacks. — The intermittents of winter and spring, as we 
have seen, are chiefly relapses, but there are, also, new cases. These are 
not to be ascribed to a reproduction of the special, remote cause, in those 
seasons, but to its impress in autumn ; which impress was not followed by 
the Fever, at that time. On. page 370, Vol. I., a case is related, in which the 



INTERIOR VALLEY OF NORTH AMERICA. 131 

Fever appeared within three days after an exposure to its remote cause. The 
case now under consideration proves, that many months may elapse, before 
its development. For the existence of such cases, I may refer to the expe- 
rience of every observing physician, who resides in regions infested with au- 
tumnal fever. Indeed the profession are familiar with vernal intermittents, 
in those who had not suffered in autumn ; all of whom, however, had been 
exposed to the remote cause. Many years since, the following fact fell under 
my own observation. A Cincinnati family made an overland journey, in 
autumn, to the State of New York, travelling slowly on the terraces of 
Lake Erie and Lake Ontario, which at that time were annually scourged 
with intermittent fever. Some of them were seized with the disease on the 
way, aud others escaped. During the next spring when the Fever was not 
prevailing in the part of the city where they resided, some members of the 
family who had suffered in autumn, were seized with it ; and at the same 
time, one of the party, who had escaped, was attacked with the same disease. 
Another, and more conclusive observation, was communicated to me by 
Doctor Smith, of Racine, Wisconsin. When he resided in Yermont, two 
men made an autumnal visit to Western New York, where the Fever was 
prevailing ; and returned without experiencing attacks. In the following 
winter, however, one of them was seized, and, in the spring, the other, with 
the same disease. No other persons were attacked; and, indeed, no case of 
the kind had before occurred, in the part of the state in which they resided. 
At Quebec, where the Fever does not originate, Doctor J. Douglas informed 
me, that he had repeatedly known persons attacked with it, several months 
after their return from more southern regions, where it was prevailing; al- 
though they continued in health while there. These cases are analogous to 
those of Irish immigrants, who are, sometimes, taken with typhus fever, 
several months after their arrival in the West. 

It is, perhaps, not correct to apply the term incubation, to the period 
which elapses in such cases, between the application of the poison, and the 
outbreak of the Fever. In the case of small-pox and of hydrophobia, there 
is a progressive, or ingravescent change, perhaps in the innervation, which 
ends in the production of specific, morbid phenomena, that do not require 
an exciting cause to bring them out. But in deferred intermittents, the 
morbid impression constitutes a mere predisposition, which slowly wears 
away; and cannot, without the aid of exciting causes, originate the Fever. 
On the evidence which these cases afford, of a specific, efficient, remote 
cause, I have already spoken. 



SECTION III. 

TREATMENT HYGIENIC AND MEDICAL. 

I. Treatment of Winter Cases. — 1. I have introduced the word 
hygienic, into the title of this section, for the purpose of strongly directing 



132 THE PRINCIPAL DISEASES OF THE 

the attention of the reader, to the more important part of the treatment. 
It may be truthfully affirmed, that after intermittent fever has been 
arrested, it would not often — perhaps never — recur, if all exciting causes 
could be avoided. Of course that is not practicable ; but every predisposed 
person should withdraw from them, as perfectly as possible. Thus, the 
hygienic regulations deserve great attention. Warm clothing, with flannel 
next the skin, and shoes that will keep the feet dry, are necessary; but the 
patient should not house himself; for that would prolong his liability. On 
the contrary, with the surface of his body adequately protected, he should 
boldly encounter the cold of winter, and take a great deal of active exercise. 
The muscular effort will increase the depuration of his blood, by promoting 
pulmonary and cutaneous transpiration, while it invigorates all his solids. 
It will, moreover, give impulse to the portal circulation, and assist in rous- 
ing the sluggish abdominal organs into healthier action. The loss of sleep 
should be guarded against. To lodge warm is essential ; but on rising in 
the morning, the surface of his body should be dashed with cold water; and 
then wiped dry, the friction being continued until it reddens the skin. 
Finally, his diet should be savory, nutritious, and digestible. 

2. The medical treatment of these cases, has been in part anticipated, 
when speaking of the cure of simple intermittents. It resolves itself into 
that which is proper to prevent the return of the disease, and that required 
when it has recurred ; and, first, of the former. 

Some persons are in the habit of taking small doses of quinine for this 
purpose ; but they often fail. They do not establish a quinic diathesis, 
which, for the time being, would always arrest the paroxysms; nor do they 
give tone to the system. As a prophylactic, in these cases, the bark is 
much to be preferred, on account of its tonic, not less than its antiperiodic 
properties. A teaspoonful before each meal, will, in general, answer the 
purpose. The impoverished state of the blood, moreover, suggests the use 
of chalybeates ; of which, perhaps, no preparation is better, than the proto- 
carbonate of iron. It may be given in an electuary with the bark ; for I am 
not aware, that the latter will lose any of its efficacy by yielding up a part 
of its tanno-gallic acid to the iron ; or that the salt thus formed, will not 
produce all the effects of any other chalybeate preparation. Recently, a new 
preparation, the ferro-cyanate of quinine, has been introduced in practice, 
and, prima facie, seems likely to be useful ; but I have not tried it, nor 
informed myself of the experience of others. Arsenious acid and opium, 
sometimes root out the predisposition to recurrences ; but to do so, their 
administration should be continued, until the arsenical oedema is produced. 
The preservation of a regular habit of body is important ; but in obviating 
costiveness, the cold and debilitating laxatives should be avoided. When 
required, powdered rhubarb may be added to the bark ; or the tincture of 
rhubarb and gentian may be chosen; or pills composed of blue mass, rhu- 
barb, galbanum, and aloes, made into a mass with extract of gentian, may 



INTERIOR VALLEY OF NORTH AMERICA. 133 

be given. Whatever medicine is chosen, it should not be allowed to operate 
more than once or twice. 

But all these things fail in some instances, and a treatment of the oppo- 
site kind succeeds. In such cases there is, probably, a subacute inflamma- 
tion of some organ, as the spleen or alimentary membrane. From Doctor 
Frye, of Illinois, I have learned, that he has frequently succeeded in these 
refractory cases, by laying aside tonics and stimulants, and administering an 
eighth of a grain of tartarized antimony, with ten grains of hydrochlorate 
of ammonia (sal ammoniac), given every two or four hours. 

We come, in the second place, to the treatment required in the paroxysm. 
If the existing symptoms should indicate functional biliary derangement, a 
mercurial cathartic will be proper; and if the stomach should be dyspeptic, 
an active emetic will do much good; but, in many cases, all evacuation may 
be dispensed with, and immediate recourse had to quinine and opium ; 
which will, almost infallibly, arrest the disease so promptly that not even 
another paroxysm will occur. The proportion of opium should be large ; for, 
in the condition of the system we are now considering, there is great tole- 
ration of that medicine. 

We must not forget, that along with these relapses, may come an inflam- 
mation of some organ, that will render these measures abortive or even in- 
jurious. Thus the very cause which reproduced the paroxysm, may revive 
or generate a hepatitis, a splenitis, or a pneumonitis, in which case a certain 
amount of the treatment, required for the inflammation, will be necessary. 
In proportion as the inflammation is severe, the signs of its existence will be 
more or less present during the intermission. I have had many patients of 
this class, whom it was necessary to bleed copiously; but, further south, or 
in places where intermittents greatly prevail, copious bloodletting is inad- 
missible, and calomel, tartar emetic, cupping and blistering, must be em- 
ployed. Everywhere, however, it is necessary to connect the opium and 
quinine practice with the depletory. 

II. Treatment of Vernal Intermittents. — The hygienic means of 
preventing vernal intermittents, are the same as for those of winter. In 
spring, as we have already seen, one exciting cause is the great diurnal 
change of temperature. The elevated heat, after the system has had its 
susceptibility to caloric increased by the cold of winter, renders many per- 
sons impatient of warm clothing, and prompts the imprudent to throw it off 
too soon. In doing this, however, they begin wrong. Instead of laying 
aside their winter coats, they take off their flannel, thus depriving the skin 
of a stimulus to which it had become habituated : whereupon it readily falls 
into torpor. Those who are strongly predisposed to attacks, generate but 
little animal heat; and, as we have already seen, instinctively expose them- 
selves to the hot sun ; which greatly increases the influence of low tempe- 
rature, in the following night and morning. In addition to all this, damp 
southwest and northeast winds, about the time of the vernal equinox, act 
with sinister effect on the inadequately protected surface. 



134 THE PRINCIPAL DISEASES OP THE 

The required treatment of vernal intermittens, is somewhat intermediate 
between that of autumnal and that of winter cases. In spring, the return- 
ing solar heat quickens the liver into action, and bilious appearances are 
then more common than in cold weather; the appetite oftener fails, and 
nausea, with other signs of gastric derangement, occurs in a greater number 
of cases. Hence, active evacuation of the stomach and bowels, is useful in 
many cases, and in some, almost indispensable. With this preparation of 
the system, or without any, in cases of a simpler kind, the antiperiodics 
maybe administered, as in winter intermittents; and generally with the 
same immediate advantage. Now and then, however, a case will prove re- 
fractory, and continue until arrested by the heat of the summer solstice. 

III. Change of Locality. — Some persons are so susceptible to the im- 
press of the remote cause of intermittent fever, or the habit of recurrence 
is so readily and firmly established in their systems, that as long as they 
continue in an infested locality, the disease will set all the efforts of art at 
defiance. Change of place must then be submitted to, or the constitution 
will be ruined. In this, two objects should always be had in view : First, 
To seek a locality where the Fever is not endemic. Second. To reach a 
cooler climate, by change of latitude, or change of elevation. The former 
end may be accomplished by entering the depths of a city; by sojourning 
on the sands of the Pine woods ; by wandering in the desert west of the 
Mississippi, or emigrating to Santa Fe ; all, without reference to a cooler 
climate. The latter end is attained by ascending the Appalachian Moun- 
tains, where the Fever is nearly unknown, and the air invigorating. Of the 
regions fitted for this purpose, one of the most eligible is that around Chau- 
tauque Lake, described at page97, Vol. I. But all the benefits of mountain 
air may be enjoyed, without ascending above the mean level of the Valley, 
six hundred feet, by going northerly. To this end, a voyage up the Mis- 
sissippi, and a summer residence in the neighborhood of the Falls of St. 
Anthony ; or a voyage to Mackinac and Lake Superior ; or down the St. 
Lawrence to Quebec, and the deep chasms of the Saguenay, in the latitude 
of forty-eight degrees, may be performed with great facility. As soon as 
the patient reaches a region in which the fever is not endemic, he feels that 
his redemption has begun ; and, in a few weeks, finds himself quite re- 
stored. In the autumn of the next year, however, he may experience a 
new attack, when he should, if practicable, change his residence for a city 
or a colder climate. 

When the constitution of a citizen of the South has, by fever or climatic 
influences, become seriously enervated, it is sometimes necessary to seek a 
colder climate, in winter, for the purpose of invigorating his constitution ; 
that of the South being too mild for that purpose. By going north, in sum- 
mer, he may, it is true, escape the Fever; but the heat of that season is 
there, for a while, high, and he may return without all the reinvigoration 
that is desired. Under such circumstances, the influence of cold is neces- 



INTERIOR VALLEY OF NORTH AMERICA. 135 

sary. "With this conviction, Doctor Cartwright, of Natchez, not long since, 
spent the greater part of a winter in the latitude of St. Louis, Louisville, 
and Cincinnati, fearlessly exposing himself, as he informed me, to the most 
rigorous winds, and returned home with a renovated constitution. 

IV. Popular Empiricism. — Where agues prevail, many cases not sub- 
jected to enlightened medical treatment, become chronic, and are at last 
broken up by some sudden impression on the nervous system. I refer to 
these experiments, not to legitimate them in our catalogue of remedies, but 
as throwing light on the pathological condition of the system ; as evincing 
that the disease, when thus prolonged, becomes a neurosis. 

A case of the kind we are considering, is sometimes permanently arrested, 
by a violent emetic, taken just before the chill. It imparts a shock to the 
nervous system, which destroys the disposition to recurrence. A country- 
man informed me, that he stopped a tertian ague of eleven months' duration 
by taking, just before the fit, a quantity of gunpowder, mixed with rum. It 
produced on his system a powerful impression ; and excited a profuse sweat, 
which continued for twenty-four hours, after which, the disease did not re- 
turn. A very copious perspiration, produced by other means, has sometimes 
succeeded. The same beneficial result has, in other cases, been attained, by 
rapid riding on a hard-trotting horse, just before the paroxysm. The sudden 
affusion of very cold water has produced the same result. Doctor Joshua 
Martin, of Xenia, Ohio, knew the disease permanently cured in a small boy, 
by standing him on his head, at the access of the fit. Here was both a corpo- 
real and mental effect. In many instances the recurrence has been arrested, 
by means which acted entirely on the imagination and feelings. Of this, 
kind are various loathsome potions, which the patients have swallowed with 
disgust; and different charms or incantations, which raise powerful emotions, 
that change the innervation, and destroy the habit of recurrence. 

V. Salutary Effects of Chronic Intermittents. — It has often 
been said, that protracted agues sometimes cure chronic diseases, and im- 
prove the health. That one disease may supersede another, from incom- 
patibility of action, is certain ; but I have not met with facts which establish 
the remedial influence of intermittent fever. On the contrary, impairment 
of the constitution, has been the general result of protracted cases. 

The alleged benefit to the consumptive, of a sojourn in localities produc- 
tive of ague and fever, will be discussed hereafter; and I will only remark 
in this place, that I once saw a paludal intermittent, unite itself with hectic 
fever ; but not to the end of effecting a cure. 



136 THE PRINCIPAL DISEASES OF THE 

CHAPTER X. 

PATHOLOGICAL ANATOMY, AND CONSEQUENCES OF AUTUMNAL FEVER 



SECTION I. 

MORTALITY OF AUTUMNAL FEVER. 

A simple intermittent fever, even when left to take its course, rarely, per- 
haps never, proves directly fatal, but it may derange the structure of some 
organ, or generate a kind of cachexia or spangemia,* from which, as patholo- 
gical causes, other, and at last fatal consequences may follow. 

Many simple remittents, in the new settlements, are allowed to run their 
course without the superintendence of a physician ; though seldom without 
some kind of medical treatment. In the early settlement of Kentucky, and 
Ohio, this was oftener the case, than in any of the new settlements of the 
present day ; for considerable districts of country were, then, without phy- 
sicians. In the former state, more than fifty years ago, I saw numerous 
cases, for which but little was done. In reference to these, as they occur 
in the middle latitudes, it may, I think be said, that they are not often mor- 
tal ; but sometimes run a course of ten or fifteen days, and gradually cease, 
or degenerate into agues. 

Inflammatory intermittents demand the interposition of art to bring them 
to a favorable termination. Left to themselves, it is true, they will not in 
general destroy life, immediately ; but the persisting inflammation of some 
vital organ may at last give a fatal termination. Under a well-known treat- 
ment, however, such cases may generally be cured. 

It is otherwise, with inflammatory remittents, which, in their advanced 
stages, often take on a typhous character, and prove fatal. Of the propor- 
tion who die, it is impossible to speak. I have proposed to our brethren, in 
various places, to send me returns of the annual relative mortality from the 
different diseases, occurring in their practice; but the amount of material 
thus obtained, is, as yet, too small to justify its presentation. I do not be- 
lieve, that simple and inflammatory remittents, are more fatal in the South, 
than in the higher latitudes ; but the mortality from them is greater, because 
they occur more frequently. 

Malignant intermittent fever, is always mortal when not arrested by art; 
and many die from it every autumn, its true character not being perceived in 
time, or the patient residing beyond the range of enlightened medical prac- 
tice. Where this variety prevails, therefore, it constitutes, in autumn, the 
chief outlet of human life ; notwithstanding a successful mode of treatment 
has been discovered. 

* From aima, blood, and spanos, poor,— poverty of the blood.— Simon's Animal Chemistry. 



INTERIOR VALLEY OF NORTH AMERICA. 137 

Malignant remittents are not so common as intermittents, but more diffi- 
cult of cure, and, therefore, much oftener fatal. 

In traversing the Interior Valley, from north to south, we find, that the 
number of deaths from autumnal fever, as compared with the number from 
all other diseases, constantly increases. In the higher latitudes, the preva- 
lence of this fever is less, the variety of diseases greater, and the deaths 
distributed more equally through the year. In the South, the chief mor- 
tality is from July to November; though, in certain winters, large numbers 
die of pneumonia, engrafted on constitutions, enfeebled and deranged, by 
the insalubrious air of the previous autumn. Still, it may be affirmed, that 
below the thirty-third parallel, the inhabitants enjoy more uninterrupted 
health, for eight months of the year, than in any other part of the Valley; 
and hence it was not without reason, that the distinguished Professor Cald- 
well, several years since, attempted to show, that taking the year round, 
New Orleans was the healthiest city on the continent. 



SECTION II. 

CONDITION OE THE BLOOD IN AUTUMNAL FEVER. 

Observation has established the fact, that the blood, in our autumnal 
fevers, may, or may not, show the buffy coat. In my own practice, it has 
been much oftener absent than present, and I have seldom seen it cupped. 
In most cases, the amount of fibrinous crust is not great; and, in the 
majority, it shows itself only in islets, or patches, which are sometimes in- 
distinct. With these observations, I have found those of a great number of 
the physicians in the middle and higher latitudes of the Valley entirely 
correspondent. It is obvious, then, that a state of hyperinosis,* is not 
essential to these fevers; and that when it does exist, and is made manifest 
by sizy blood, it is at once the effect and sign of an accidental inflammation. 
In general, the clot is large and soft, resting on the bottom of the bowl, and 
not swimming in serum, because the contraction has not been close enough, 
to press out that fluid, in large quantities. This may, in some cases, arise 
from the plethora of the patient before his attack, in which condition the 
red corpuscles are increased in quantity ; in others, there may be a state of 
hypinosis,f or deficiency of fibrin. J In reference to the former, I may say, 
that men of a sanguineo-lymphatic temperament, the usual subjects of ple- 
thora, are oftenest the subjects of autumnal fever. The serum in this 
disease, is sometimes yellow from the coloring matter of the bile ; but I 
have not found it bitter. 

I do not know, that any experiments have been made on the relative pro- 
portion of the proximate elements of the blood, in our autumnal fever. 

♦From hyper, excess, and is-inos, the fibre of the flesh, f From hypo, deficiency, and is-inos. — Simon. 
J Essay on the Blood in Disease. — Andral. 



138 THE PRINCIPAL DISEASES OF THE 

Andral and G-avarret, in the hospitals of Paris, made such experiments on 
the blood of seven patients, laboring under intermittents of long standing ; 
and found the mean proportion of fibrin to be three and a third of one 
thousand parts, the normal quantity being three. As many chronic cases 
of the Fever, are made such by inflammation of some organ, we may pre- 
sume, that in these cases some were complicated with such inflammations. 
As to the other proximate elements of the blood, the solid residue of the 
serum, was eighty parts in the thousand, the natural proportion ; but the 
blood-corpuscles were, on an average, one hundred and four parts in a thou- 
sand, while one hundred and twenty-seven, is the normal number. Thus, 
it appears, that protracted intermittents, produce impoverishment of the 
blood — spansemia — the condition present in chlorosis ; and this accounts, in 
part, for the peculiar hue and puffy visage, of old ague patients, who so 
closely simulate chlorotics, in their appearance. 



SECTION III. 

PATHOLOGICAL ANATOMY OF INTERMITTENT FEVER. 

It has been already said, that our simple intermittents do not prove fatal; 
how then can we know, by anatomy, whether any single organ always 
suffers ? If any one be invariably affected, it is undoubtedly, the spleen, if 
we may depend on what is presented by patients laboring under chronic 
and relapsing agues. Our inflammatory intermittents, moreover, but seldom 
prove mortal; but they often show signs of splenitis; and when the subjects 
of them die, subsequently, of other diseases, it is common to find vestiges 
of serous splenitis, in old and firm patches and bands, of coagulated lymph ; 
which sometimes distort the organ, and at other times compress it, and, by 
limiting its circulation, produce a state of atrophy. During the ten winters 
in which I delivered clinical instruction in the Louisville Commercial Hos- 
pital, my colleague, Doctor, now Professor Bayless, and myself, met with 
many examples of what is here described; the patients having died of other 
maladies than intermittent fever. 

The anatomy of our malignant intermittents ought to be well known, but 
it is not ; for in the country, the prejudices of the people against post-mor- 
tem inspections, especially after death from common diseases, is almost un- 
conquerable ; and in our cities the disease scarcely ever occurs. It must 
be confessed, moreover, that from want of practice in dissections, many of 
our brethren, living in new and remote settlements, infested with this fever, 
are not as well prepared to report on morbid appearances, as some of those 
who have greater opportunities of cultivating pathological anatomy, in 
places where the Fever seldom occurs. In travelling, I was only able to 
collect the subjoined observations. 

1. Assistant-Surgeon Holmes, gave me the following case. A soldier, in 



INTERIOR VALLEY OF NORTH AMERICA. 139 

Florida, of intemperate habits, but vigorous constitution, died in sixteen 
hours, that is, in the first fit of a malignant intermittent. The chief signs 
of congestion during life, were in the chest, the parietes of which, displayed 
an ecchymosed appearance. Blood could not be obtained by venesection. 
Eight grains of tartar emetic operated as a cathartic; after which he took 
large doses of the sulphate of quinine. On examination after death, the 
mucous membrane of the stomach was found healthy ; that of the bowels 
had more or less congestion; the liver showed signs of the same condition; 
and the spleen was double its natural size ; but healthy in texture and ap- 
pearance. The cavities and substance of the heart were engorged, and the 
lungs were loaded with blood. The brain was not examined. This indi- 
vidual had probably experienced a previous attack of intermittent fever, 
which produced the enlargement of the spleen, and hence its natural ap- 
pearance, except in size. The fatal congestions were in the lungs, as the 
symptoms indicated. 

2. Another case from the same gentleman : A soldier, who had labored 
under chronic diarrhoea, was taken in the morning, and died at night. His 
brain seemed to be deeply implicated ; as he experienced numbness, had 
a vacant gaze, lost the power of speech, and became insensible ; but still 
continued to sit up, until he was about to expire. He was cupped on the 
neck, had a stream of cold water poured on his head, while his feet were 
immersed in a hot bath, and took large doses of the sulphate of quinine 
and carbonate of ammonia — all without effect. Post-mortem appearances. — 
The external parts of the head were in a state of congestion, and the brain 
was covered with engorged vessels, but its substance showed very little 
hyperemia. The lungs were moderately engorged. The stomach and 
bowels showed traces of inflammation. As this patient had labored under 
chronic diarrhoea, it may be presumed that the latter condition existed 
before the fatal attack. 

3. The following observation was given me by Dr. Boling and Dr. Bald- 
win, of Montgomery, Alabama : A man had the characteristic symptoms, 
but the fits were so mild, that he rose from his bed, and " kept about" 
between them, for five or six days. The fatal paroxysm then came 
on, and he died in twenty-four hours. During the disease, his tongue was 
dry, smooth in the middle, furred on each side, and red at the edges and 
tip. Post-mortem appearances. — His stomach was empty. In its greater 
curvature, near the pylorus, patches of hyperemia, with softening. The 
small intestines, particularly the lower part of the ileum, exhibited the 
same appearance. The spleen and liver were healthy. 

4. I am, indebted to Dr. Sims, of the same city, for the following : A 
man, not attended by him, was said to have died in the second or third 
paroxysm, with the usual symptoms. The dissection was commenced before 
the body had entirely lost its heat. The lungs, liver, and spleen, with all 
the venous trunks connected with them, were distended with uncommonly 



140 THE PRINCIPAL DISEASES OF THE 

dark blood. The stomach contained the medicines, not spread over it, but 
was natural in appearance, and so were the bowels ; but near the ileo-coecal 
valve, there was a quantity of black, tar-like matter, similar to the contents 
of the gall-bladder. 

5. Dr. Pennick, of Wetumpka, Alabama, observed the following case : 
A man was taken with what appeared to be an ordinary chill, but became 
dizzy; and falling, cut his scalp through to the skull. In the first fit, his 
breathing was embarrassed j in the second, it became stertorous, and he 
died. On examination, his brain was found in a state of congestion, with 
serum in the ventricles. The mucous membrane of the stomach, exhibited 
a spot of a dark, modena-red color, and that of the bowels, two others of 
the same kind. 

6. Several physicians, of Greensboro', Alabama, in the course of their 
joint conversation with me, on malignant intermit tents, mentioned two post- 
mortem inspections, which they had witnessed. In one, there was consi- 
derable engorgement of the brain ; in the other, a great congestion and 
enlargement of the spleen. The splenic region was tender, before death. 
No other morbid appearances were recollected. 

7. Dr. Haywood, of Tuscaloosa, in the same state, informed me, that he 
had made a number of dissections of persons dying of this fever, in which 
he could detect no morbid appearance, except, in a part of them, a slight 
hyperemia of the mucous membrane of the stomach, which he supposed to 
have been produced by medicines. 

8. Dr. Echols, of Selma, in the state just mentioned, informed me, that 
he had examined several who had died of the disease, without finding any 
morbid appearances, except enlarged spleens in a part of them. 

9. Dr. Christian, of Memphis, Tennessee, had examined a few subjects, 
in which he found the stomach but little altered ; in one case (which must 
have been protracted), the liver was suppurating ; in others that organ was 
enlarged ; in most of them the spleen and brain were engorged. 

10. Dr. Frye, of Peoria, Illinois, had examined two subjects, dead from 
the same fever. One of the patients had labored under incessant and un- 
controllable vomiting. The stomach and liver were found in a state of 
congestion. The spleen was enlarged and softened. 

11. Dr. Ridgely, of Cincinnati, examined the abdominal organs of a boy 
five years old (see Vol. I., page 80), who died of the Fever, and found the 
stomach and bowels free from lesion ; the liver was unusually firm, and of a 
leaden hue ; the spleen enlarged, engorged, and of a dark color. 

12. A gentleman, living in the interior of Indiana, had his constitution 
impaired by several attacks of the Fever. Three years elapsed without any, 
though he continued in the same locality ; but he was none of the time in 
perfect health. He then undertook a summer visit to Cincinnati ; and, on 
the way, had a malignant paroxysm. On reaching the city it recurred, 
and Dr. Ridgely was called in. He found the skin of the patient cold, and 



INTERIOR VALLEY OF NORTH AMERICA. 141 

of a dark and dirty copper hue, which it had exhibited for some time before; 
his pulse was feeble and rapid ; his mind wandering with short periods of 
drowsiness. In a few hours he expired. A. post-mortem inspection revealed 
the following lesions : The lungs slightly engorged ; heart softened and 
apparently atrophied ; mucous coat of the stomach and bowels softened ; 
liver somewhat enlarged, tender, and friable ; spleen enlarged, and almost 
decomposed into a grumous mass. Finally, a most offensive putrefaction 
followed in a few hours after death. In this case, no doubt, many of the 
lesions had been produced by previous attacks of the Fever. 

Although these observations offer very little that meets the demands of 
exact pathology, seeing that the brain and spinal cord, with a few exceptions 
in favor of the former, were not examined, and that the lesions of the other 
organs are given in a vague and general manner, still they are not alto- 
gether valueless, and we may devote a paragraph to their generalization. 

1. In several cases, very few traces of disease were found. The patients 
died from nervous depression ; and whatever congestions may have been 
formed, nearly disappeared, while the patient was in articulo mortis. 

2. In the cases in which the brain was examined, it was generally found 
in a state of congestion j which is, perhaps, its invariable condition in sopo- 
rose cases. 

3. In the first case, characterized by pulmonary symptoms, the lungs were 
found in a state of great congestion ; and, in several others, they were more 
or less in that condition. 

4. The stomach and bowels in each patient were in nearly the same 
degree of lesion ; but in none were the traces of disease great. In several, 
those organs were natural ; in about an equal number more or less con- 
gestion existed; but in two or three only was it regarded as inflamma- 
tory. 

5. The liver, in several of these subjects, exhibited signs of congestion; 
in others it was quite natural ; in one suppurating ; in another dense to the 
touch ; both of which conditions probably existed before the attacks of which 
the patients died. 

6. The spleen was, on the whole, oftener affected than any other organ ; 
but in one case it was reported natural ; in several, not mentioned ; when 
we may presume it was in the same condition ; in the majority of the subjects, 
it was engorged and enlarged. 

To sum up, we may say, that the signs of inflammation were few and un- 
certain ; that passive congestions were common ; that they occurred in the 
brain and lungs, but still oftener in the abdominal organs ; above all, in the 
spleen ; but that no organ was always affected, and consequently that none, 
according to these observations, is the invariable and characteristic seat of 
lesion. 



142 THE PRINCIPAL DISEASES OP THE 

SECTION IV. 

PATHOLOGICAL ANATOMY OF REMITTENT FEVER. 

I. A remark already made, concerning our knowledge of the lesions of 
structure in simple intermittents, is, to a certain extent, applicable to simple 
remittents. As they generally terminate in health, we can only judge from 
the symptoms, what organ or orgaus are especially affected. In many cases 
they degenerate or change into agues ; and in time bring about the visceral 
derangements, consequent on chronic intermittents. But simple remit- 
tents have a mode of termination which distinguishes them from all inter- 
mittents. It is the typhous state or stage. In this metamorphic fever, the 
brain is always affected, either with simple hyperemia, mere irritation, or 
inflammation. When coma, supervening at an early period of the change, 
is the prominent symptom, the first of these pathological conditions is per- 
haps predominant; when the supervention of cerebral symptoms has been 
sudden — and they consist of coma-vigil and delirium, with feeble and fre- 
quent pulse, active subsultus tendinum, and a locomotive propensity, — the 
second or irritable state of the brain exists; when the vigilance becomes 
morbid, with wild, loquacious, and singing delirium, cold feet, hot forehead, 
red eyes, contracted pupils, pulsating carotids, and more or less subsultus, 
with efforts at locomotion, inflammation may be assumed to exist; yet I 
have seen these symptoms, not excepting a closely-contracted pupil, imme- 
diately relieved, and recovery follow a large dose of laudanum j proving 
that they may depend on irritation only. Nevertheless, it may, I think, bo 
received as a fact, that when patients die in what is called the typhous stage 
of simple remittent fever, it is generally from cerebritis ; and that, after 
death, the principal lesions would be found in the brain, in the form of 
hyperemias, and serous or fibrinous secretions ; to which softening, perhaps, 
may sometimes be added. This cerebritis, however, cannot be admitted as 
an original affection, characteristic of the Fever. 

But we must turn from the brain to other organs. The lungs, it is well 
known, are liable to inflammation in this fever ; and instead of occurring 
late in the disease, like cerebritis, it generally arises at an early period. 
Such inflammation may prove fatal; and then a post-mortem inspection will 
show the lesions resulting from bronchitis or pleurisy ; but more frequently 
still those of pneumonia, such as sanguineous engorgement and hepatiza- 
tion. But they cannot be regarded as constant, essential, or characteristic 
of autumnal fever; for, first, a vast majority of cases, even those which 
prove fatal, do not present a single symptom of pulmonary inflammation ; 
and, second, this inflammation, in most instances, is the undoubted effect of 
the sudden changes of weather in the latter part of autumn ; and must, 
therefore, be taken as the offspring of an incidental cause, acting subse- 
quently to that which produced the Fever. 



INTERIOR VALLEY OF NORTH AMERICA. 143 

We are thus driven to the abdominal viscera, in our search after a lesion 
which may enter into the definition of remittent fever ; and, which, being 
shown by symptoms during life, must be found by dissection after death. 
In all times and places, it has been observed, that this fever is accompanied, 
from the beginning, with functional derangements of the abdominal organs ; 
and, in many cases, there are unmistakable symptoms of inflammation. 
The functional disturbances are found chiefly in the liver, stomach, and duo- 
denum. To speak of functional disorders of the spleen, when we know 
not what its function is, would be an absurdity. Should the life of the 
patient be destroyed, while mere functional derangements prevailed, no 
morbid appearances might be found after death. They are but perturbations 
of the innervation, which carry into the circulation and secretions an 
altered action, different from that of inflammation. In simple remittents 
these disruptions of function may continue without generating derange- 
ments of structure, until the fever spontaneously ceases, or is reduced by 
art ; in the highest grade of malignant remittent fever, the irritation and 
prostration of the whole nervous system may be so intense as to destroy life 
in two or three paroxysms, leaving no lesions of structure to be revealed 
by the knife. 

But abdominal inflammation does occur in both inflammatory and malig- 
nant remittents. Moreover, it often commences with, or early in the Fever, 
and declares itself by legitimate signs. It arises independently of any co- 
operative or exciting cause ; and, therefore, results from the same agency 
with the Fever. Finally, by its ravages, it shows itself to the anatomist 
after death. But is it always in the same part ? It is not. There are 
three organs in which it is chiefly found. They are the spleen, gastro-duo- 
denal mucous membrane, and liver. Occasionally it invades the whole at 
the same time ; but oftener limits itself to two, and in many cases affects 
one only. None of them is affected in some cases ; and, therefore, there is no 
inflammatory lesion in the abdominal viscera, which constitutes a peculiar 
anatomical character of remittent fever j any more than there is an ever 
present uniform lesion in those who die of intermittent fever. But we 
must proceed to inquire into the evidences afforded by autopsic examinations. 
II. Post-mortem Eevelations. — The facts supplied by our Valley for 
illustrating the pathological anatomy of remitting fever, are still fewer than 
for our intermittents. I am compelled, therefore to look abroad; but, am 
sorry that in doing so, I cannot find materials for a very full and satis- 
factory history. 

At all times, occasional examinations have been made in Europe, the 
Atlantic States, and the Interior Valley; but they only announced, in gene- 
ral terms, the existence of congestion, softening, and inflammation, found in 
different cases, in all the organs of the cranium, thorax, and abdomen. A 
series of careful post-mortem inspections, by an able pathologist, was still 
wanting; and a few years since, Doctor Stewardson undertook to supply 



144 THE PRINCIPAL DISEASES OF THE 

the desideratum. * His dissections, seven in number, were made in the 
Pennsylvania Hospital, in the months of August, September, and October, 
which constitute the true period of prevalence of this fever. 

The following is his summary of the pathological appearances. 

" Brain. — This organ was examined in only five of the cases. The sub- 
arachnoid effusion was either entirely wanting, or moderate, except in one 
case, where there was a considerable quantity of reddish serum. In the 
same case the ventricles contained an ounce of bloody serum, whilst in two 
of the others they were empty, in a third nearly so, and in the fourth con- 
tained scarcely a drachm of fluid. In one the walls of the ventricles were of 
a yellow color. The pia mater was deeply iDj'ected in one case, in which also 
there appeared to be a slight effusion of blood into the cells in a small cir- 
cumscribed space ; its veins much distended posteriorly in another. The 
cortical substance was of a deep shade in two cases, and in none is it men- 
tioned as being paler than natural or presenting other alteration. In two 
cases the medullary substance was natural ) in a third it felt pasty without 
giving the sensation of softness ; while in a fourth it was soft and pasty, 
being at the same time dry and of a milk-white color, with few bloody points. 
In a fifth its color was a dirty white, mixed with a faint reddish brown, its 
consistence natural, with the exception of slight central softening. The 
same condition was presented by the cerebellum, which was natural in three 
other cases; its condition not noted in the fifth. 

" The above alterations are similar to those found in other acute diseases, 
and must be regarded as slight and comparatively unimportant, if we except 
the individual in whom there was large bloody effusion in the ventricles, etc., 
and whose case will be reported further on. 

" Respiratory Apparatus — Pleura. — Old adhesions were found in a 
few cases, but very limited in extent. In two instances there was effusion 
in each pleural cavity, of about half a pint of a reddish brown or bloody- 
fluid. In both of these cases the heart was flaccid, its lining membrane 
deep red or reddish brown, and in one the pericardium also contained several 
ounces of bloody serum. The lungs, on the contrary, in one of these cases, 
were healthy, in the other, very dark, deeply congested, without hepatiza- 
tion. It is most likely, then, that the pleural effusion was the result rather 
of an altered condition of the blood, combined, perhaps, with some softening 
of the tissue, than upon obstruction to the pulmonary circulation. That 
pleural effusion was generally absent or slight in the other cases, I have little 
doubt, but its absence is not positively noted. 

"Lungs. — Of the six cases in which these organs are particularly de- 
scribed, hepatization was found in one case only, and that at the summit 
merely of the middle lobe. They were generally more or less supple and 
crepitant, sometimes dark posteriorly ; in one instance yellowish in the upper 
lobes, but deep reddish brown in the lower, in which case also spumous fluid 

* American Journal of the Medical Sciences, for 18-11 and 1842. 



INTERIOR VALLEY OF NORTH AMERICA. 145 

of corresponding color, but most abundant in the lower lobes, issued from 
the several parts when squeezed. Indeed these organs presented nothing 
particularly remarkable, except in one instance (Case III.), where they were 
highly congested, their color throughout nearly their whole extent being very 
dark, almost black, and the tissue but slightly crepitant, though not granu- 
lated or very easily penetrated. 

"The condition of the lungs, then, was much the same as in most other 
acute diseases, not especially seated in these organs. It is worthy of re- 
mark, that in no instance were there any of those hgemorrhagic masses 
frequently occurring in the yellow fever, according to the description given 
us by M. Louis, while, in both, hepatization was very rare. 

" Circulatory Organs. — The pericardium contained a small quantity of 
serum in one case, and several ounces of bloody serum in another. 

11 Heart. — This organ was flabby in three of the six cases in which it is 
particularly described, and combined with this flabbiness, there was dimi- 
nished consistence at least in two cases. In the same three cases its lining 
membrane was reddish brown, deep red, or violet ; in two of these the color- 
ing being deepest on the right side and in the neighborhood of the valves, 
and extending into the pulmonary artery and aorta. In the other three 
cases the heart presented nothing remarkable ; in all, its valves were supple, 
and in one case of a yellow color. The aorta was of a bright or lemon yel- 
low in two cases. 

" In the five cases in which the state of the blood is mentioned, this fluid 
was found in the cavity of the heart. In one case there were black coagula 
mixed with red serum ; in the others fibrinous coagula, soft in two, semi- 
transparent and greenish in another, and generally small. Xo large, firm, 
fibrinous coagulum was found in a single instance. Although it is impossi- 
ble to say, at present, whether or no blood in remittent fever presents any 
characters which are absolutely peculiar, it is perfectly evident that it is the 
seat of morbid changes which deserve especial attention. 

" Abdomen. — A few ounces of a bistre-colored fluid were found in the 
peritoneal cavity in one case ; in another, a part of the peritoneal coat of the 
gall-bladder, and of the neighboring folds of the small intestine were of a 
rose color, and covered with false membrane. The omentum, and many of 
the folds of the small intestine, are noted in one case as olive-colored, there 
being no effusion in the cavity ; in another, the intestines were of a dingy 
ash color, and pasty feel. 

"Liver. — Enlarged in three cases, and in one of them to a great degree; 
in the others it was of natural or moderate size. The consistence of the 
organ appears to have been generally diminished, being flabby, or softened, 
or both, in four cases, a little soft in a fifth, and moderately firm, but still 
readily penetrated by the finger, in a sixth ; in the seventh, the consistence 
is not mentioned. 

" The color was nearly the same in every case ; but very different from 

VOL. II. 10 



146 THE PRINCIPAL DISEASES OF THE 

natural. In most of the cases the liver is described as being of the color of 
bronze, or a mixture of bronze and olive ; in one as a dull lead color exter- 
nally, internally bronzed with a reddish shade; in another as between a 
brown and an olive, the latter predominating; and finally, as a pale slightly 
greenish lead color, with a tinge of brown, in one instance. Few things 
are more difficult than a description of color. The most correct idea of that 
before us would perhaps be conveyed by stating its predominant character, 
the same in every case, to be a mixture of gray and olive, the natural reddish 
brown being entirely extinct, or only faintly to be traced. This alteration 
existed uniformly or nearly so throughout the whole extent of the organ, 
except in a single instance, where a part of the left lobe was of the natural 
reddish brown hue. As the alteration of color pervaded both substances, 
the two were frequently blended together, and the aspect of the cut surface 
remarkably uniform. In one case, however, there was a marked distinction 
of color, the olive being predominant in the parenchyma, the brown in the 
acini. Of the four cases in which these characters are mentioned, the cut 
surface is described as smooth in three, of a shagreened appearance, and 
rough in the left lobe, in the fourth. This last character was evidently 
dependent upon hypertrophy of the lighter colored substance, which existed 
also in another instance, both cases, however, being examples of a very pro- 
tracted form of the disease. 

" The nature of the lesion of the liver above described, characterized 
essentially by a peculiar alteration of color, is not easily determined. That 
it is the result of inflammation will hardly be contended, and even if attended 
with congestion (which I think very doubtful), this could not account for 
it, as congestion is frequently present in other diseases where no such altera- 
tion of color is observable, and where, on the contrary, its effect is to pro- 
duce a deeper red. Some, perhaps, will look upon it as dependent upon the 
infiltration of bile into the tissue of the organ, but still it will at once be 
perceived that this presupposes a peculiar alteration of the bile and liver, 
inasmuch as the appearance presented is not found in other diseases, at least 
so far as I am aware. In saying that this lesion is found in no other disease, 
I wish to be understood as excepting those cases of pernicious and other 
intermittents, which prove fatal in the early stage, or before giving rise to 
well-developed cirrhosis, abdominal effusion, etc. Indeed, I think it highly 
probable that the same alteration of the liver will be found to exist in inter- 
mittents which thus prove fatal; an opinion confirmed by the case last de- 
tailed. In speaking, therefore, of this alteration being peculiar to remit- 
tent fever, I wish to be distinctly understood as not excluding intermittent 
fever, which, in my opinion, is essentially the same disease. 

" The lesion in question, then, being peculiar to the disease before us, 
and the only one which is so (all the other lesions being common to it and 
other diseases), and at the same time being found, as already observed, in 
every case, we are obliged to admit that it constitutes its essential anatomical 



INTERIOR VALLEY OF NORTH AMERICA. 147 

characteristic, or at least that such is the conclusion to be derived from the 
cases before us. Their number, I am aware, is insufficient to establish such 
a point conclusively, and it therefore remains for future observers to deter- 
mine whether or no the lesion we have described belongs to the disease under 
all circumstances. That such will be found to be the case, I confess, seems 
to me very probable, when I recollect that the cases we have been examining 
were distributed over three successive seasons, and originated, not in a single 
locality, but in different and widely separated places, and also that by a 
reference to the description of authors, it is apparent that a similar condition 
of the liver has been frequently observed by them, without, however, attract- 
ing that attention which it seems to me it demands. 

" Whatever may be the results of future observation in reference to the 
constant occurrrence of this lesion, and even if the conclusion to which I 
have arrived, that it constitutes the essential anatomical characteristic of 
remittent fever, be found erroneous, owing to its absence in a certain portion 
of cases, it is still worthy of attention. It certainly constitutes a most pecu- 
liar and important anatomical feature of the disease. Its connexion with 
certain symptoms during the early and middle period of the disease, its ten- 
dency to joass into cirrhosis in protracted cases, and thus lay the foundation 
of certain chronic organic alterations, abdominal effusion, etc., and the assist- 
ance it must afford in determining in fatal cases the diagnosis between re- 
mittent and other fevers, are sufficient to convince us of its claims upon our 
attention. The striking difference between it and the alteration of the liver 
which belongs to yellow fever is particularly interesting, especially as it 
was found quite as strongly marked in the case which most nearly approached 
I to the latter disease, as in any of the others. While in remittent the liver 
is of a dull bronze or between a gray and olive, in yellow fever it is pale 
and of various shades of yellow, as straw-yellow, gum-yellow, etc. In typhoid 
fever the liver appears to present no other change of color than what arises 
from an increase or diminution of the red tint, being sometimes of a darker 
red, at others paler than natural." 

After Doctor Stewardson, Doctor Powers made a number of autopsic ob- 
servations, on the same fever, in the Baltimore Almshouse. He found the 
spleen, in every case, enlarged and softened. The liver was, generally, large, 
soft, and friable; but not in a state of congestion. Its color, in different 
cases, was grayish bronze, slaty bronze, and dark slaty gray. 

Doctor Swett has since extended these researches, in the New York Hos- 
pital.* His cases, five in number, were from the South and West; but not, 
in general, as well marked as those of Doctor Stewardson. The brain, in 
most of the subjects, was healthy, although they had delirium and coma 
during life; the heart was either natural, or flabby and softened; in two 
cases the lungs showed signs of pneumonia; and taking the whole of the 
cases together, he found more decided evidence of inflammatory action in 

* American Journal, Medical Sciences, for January, 1845. 






148 THE PRINCIPAL DISEASES OP THE 

them than any other organ. Referring to the stress, which Doctor Steward- 
son had laid on the pathological condition of the stomach and bowels, as 
suggesting that mucous inflammation is an important and frequent feature 
of the Fever, Doctor Swett remarks — "I am unable to confirm this opinion. 
Most of the changes that I have observed in the mucous membrane of the 
stomach, have appeared to me of a chronic nature; and probably long antece- 
dent to, and entirely independent of the acute disease. I refer, particularly, 
to the thickened and mammillated condition of the organ. The injection 
of the mucous membrane, although present in all the cases to a certain ex- 
tent, did not appear to me, beyond what is commonly noticed in other acute 
diseases, and might, in some cases, at least, be referred distinctly to simple 
post-mortem venous congestion. The symptoms during life, appear to me to 
strengthen this idea. The patients very seldom complained of pain in the 
region of the stomach, and although slight tenderness on pressure was fre- 
quently noticed, yet this did not exceed, I think, what is noticed with equal 
frequency, in other febrile affections. " 

Dr. Stewardson, also remarks, that traces of inflammation exist on the 
mucous membrane of the duodenum, and notices particularly, an enlarged 
condition of the mucous follicles. This view, also, I have beeniunable to 
confirm." ,....." The mucous membrane of the intestinal canal, exclu- 
ding the evidences of chronic disease, or of disease that had probably for a 
long time ceased to exist, was found healthy. The symptoms during life 
confirmed this opinion. The absence of diarrhoea, of abdominal pain, and 
tenderness, of tympanitis, the ease, and even the feeling of relief with which 
purgatives acted, all go to prove the absence of at least inflammation in those 
important organs. " 

In every subject, the spleen was more or less enlarged, and engorged — in 
some softened. The state of the liver will be best given in his own words. 
" It will be perceived that, in the five cases above detailed, the peculiar 
condition of the liver, which Dr. Stewardson has assumed as the anatomical 
characteristic of remittent fever, was uniformly found." . . . " Two im- 
portant considerations naturally present themselves here. First, what is the 
nature of this condition of the liver ? The only positive change that I have 
been able to observe, is that of color — the slaty and bronze tint externally, 
the olive tint internally. It is true that a slight degree of softening of the 
tissues seems to exist, in connexion with this change of color, but this has, 
in all my cases, been very moderate in degree, and, in one of the best marked 
cases of the disease, extremely doubtful. All will admit, I think, who have 
examined such cases, that there is no evidence of inflammation in the 
changes noticed, for although some degree of capillary injection existed in 
two of the cases, yet in the remaining three it was entirely absent. The 
natural size of the liver, the absence of lymph or pus, the small quantity of 
blood yielded by pressure, as well as the local symptoms during life, espe- 
cially the absence of pain and tenderness over the region of the liver, tend to 



INTERIOR VALLEY OP NORTH AMERICA. 149 

confirm the same idea. It appears to me not an unreasonable conclusion, to 
suppose that the change of color is produced by the action of the bile, espe- 
cially, when we remember the appearance of this secretion as observed in 
the gall-bladder. 

" Another important fact to establish is, whether this appearance of the 
liver may not be found in other diseases, and particularly in other forms of 
fever. This question can only be settled by long and multiplied observa- 
tion. I can only say that, in six fatal cases of continued fever, four of which 
originated on shipboard, and two in this city, no such condition was found, 
and that, after careful examination with this object in view." 

My own occasional autopsies have afforded results, which correspond very 
well with those which have been detailed; but I must confess that my atten- 
tion was not attracted to the peculiar color of the liver, first distinctly pointed 
out, I believe, by Dr. Stewardson ; though a modification of color in that 
organ had often been mentioned before. Dr. Swett has intimated, that such 
a change might be looked for, in the organ which secretes the bile. We 
know, that green discharges are not uncommon, and a bluish fluid is occa- 
sionally ejected. Dr. Hollingsworth, of Mississippi, has communicated to me 
a case, in which for many days, the patient continued to have copious evacua- 
tions of that hue. As the febrile action in this fever is of a peculiar kind, 
it is reasonable to suppose that the organ charged with forming the yellow 
coloring matter of the bile, may produce a tint of a different kind. Thus, 
the change of complexion, does not necessarily, require us to infer a struc- 
tural lesion of the liver. In fact, apart from the altered hue, the liver is, 
apparently, much less affected than the spleen. Another evidence, that it 
is not always deeply implicated, is to be found in the fact, that during many 
remittents, there are daily discharges of healthy-looking, yellow bile ; and, 
that, during convalescence, the organ generally acts very well ; finally, that 
fewer hepatic, than splenic diseases, follow on the Fever. The results which 
have been recounted, show that the spleen is, generally, if not always, in- 
volved; and the mucous membrane of the stomach and bowels very fre- 
quently. 

But the admitted ravages of inflammation are neither constant nor strik- 
ing : not sufficient, I think, in most instances, to account for the death of 
the patient; unless we include among them all cases of congestion and 
softening, which would certainly be gratuitous. Passive hyperasmia is an 
unquestionable pathological fact ; and fever softens every tissue of the body. 
To the latter type of morbid action, we may refer the soft and flabby state 
of the heart, not less than of the liver, spleen, and mucous membrane of 
the stomach and duodenum. In a case communicated to Doctor Steward- 
son, by Doctor Rowland, of Baltimore, the spleen did not bear lifting, any 
better than a clot of drawn blood bears it ; and many others have observed 
the same phenomenon ; which indicates a decomposition of the vascular and 
fibrous tissues of the organ. The soft and pulpy state of the mucous mem- 



150 THE PRINCIPAL DISEASES OF THE 

brane, with but little appearance of hyperemia, is doubtless of a febrile, 
rather than phlogistic origin. In a post-mortem examination by Dr. Harper, 
which I attended, at the Vicksburg Hospital, in 1844, the mucous mem- 
brane of the stomach was soft, tender, thickened, and easily detached ; but 
there was only here and there a spot of hyperemia. It is worthy of remark, 
that the duodenum in this case was sound. 

We may, on the whole, conclude, that although more or less inflammation 
arises, perhaps in every severe and protracted case of this fever, and may 
often be the cause of death, it is not necessary to the existence of the Fever ; 
which in many cases proves fatal, independently of the lesions, which in 
others it produces. 



SECTION V. 

CONSEQUENCES OE AUTUMNAL FEVER. 

I. Chronic Action of the Cause of Autumnal Fever. — This seems 
to be a suitable place in which to inquire, whether the cause of autumnal 
fever can act upon the system, to the production of morbid conditions, other 
than the Fever itself. There are etiological agents, as the variolous poison, 
which either produce no effect, or occasion a full development of the dis- 
ease ; there are others, equally specific, as that of epidemic cholera, which 
affect the system with every grade of violence, from the slightest diarrhoea, 
to mortal collapse; finally, there are others still, as vicissitudes of weather, 
which produce in one person catarrh, in a second, tonsillitis, in a third, 
rheumatism, in a fourth, a fit of dyspepsia. There is, then, no objection, a 
priori, to the opinion, that the cause of autumnal fever may exert injurious 
influences of a lower grade, and a different kind, from that Fever. Whether 
such be the fact, can only be known by observation. 

That the agent we are now considering, can act in a gradual and feeble 
manner, to the end of slowly developing intermittent maladies of a mild 
character, is what I can testify; and as the consequences of autumnal fever, 
as found in different parts of the body, we may, I think, conclude, that the 
slow and insidious operation of the noxious agent may generate various dis- 
eases, or at least, diatheses and predispositions to them. But for the full 
illustration of this subject, a more ample store of facts than I possess, is 
•required. 

Over most of the Interior Valley, a ruddy complexion is rare, and often 
replaced by a slight turbid hue, or a tinge of sallowness. When standing 
before the medical classes of Lexington, Louisville, and Cincinnati, com- 
posed chiefly of young men between twenty and thirty years of age, I have 
seen very few with plump and rosy cheeks. In general, the malar bones 
appear prominent, from defective cellular development of the cheeks. These 
deficiencies exist in various degrees ; and are greatest among the people in 



INTERIOR VALLEY OF NORTH AMERICA. 151 

what are called malarial districts. When we mingle with them, we see con- 
clusive evidence that their physiology is not sound, although they may re- 
gard themselves as in health. Those of the worst aspect, have generally 
experienced one or more attacks of fever, which have left them infirm j but 
others have never suffered from that disease, and yet they are not vigorous, 
in appearance or reality. They who have constaotly breathed the atmo- 
sphere of such localities, and have suffered attacks of fever while young, are 
often stunted in their growth, and never reach the port or portraiture of per- 
fect manhood. But before we ascribe these effects to an empoisoned atmo- 
sphere, only, we must recollect that heat and moisture generally prevail in 
such localities; and grant, that an undefinable portion of the injury should 
be attributed to them. 

If we admit the reality of what has been set forth, and connect with it a 
periscope of the Valley, but recently become the abode of civilized man — as 
yet, in its oldest settled portions, but in the transition state — many parts 
abounding in swamps, others intersected with alluvial streams, and almost 
everywhere overshadowed with forests, we may presume, that a national 
physiology, with its peculiar infirmities and predispositions, is, or must, 
necessarily be the consequence. This, if I mistake not, is actually the case 
at the present time ; and constitutes a reason why bloodletting and other 
active evacuations are not borne as well by those who live in low paludal 
districts, as those who inhabit higher and drier localities. In the former, 
many diseases, not inherently periodical, display more or less of that type ; 
evincing that the constitutions of the inhabitants have been acted upon by 
the cause of autumnal fever. 

II. But we must inquire whether the people in such places are liable to 
any actual diseases, periodical fevers excepted, which may be regarded as the 
products of the conditions under which they live. 

Comparing the early and the latter frequency of biliary derangements, in the 
same localities, it seems to me, that with the progress of cultivation, and the 
density of population, the present has a decided advantage over the past ; 
and a comparison of country and city, leads to the same conclusion. In 
former times, I have witnessed, more than once, an epidemic jaundice, in 
autumn, which it appeared natural to refer to the cause which produced fever, 
in that season. Dyspepsia has, also, seemed in many cases, to be the off- 
spring of the same agency. Chronic, or subacute hepatitis, I am almost 
convinced, has often been generated by the same agencies ; and it is an ad- 
mitted fact that the spleen may become enlarged in these localities, without 
the previous occurrence of a single paroxysm of fever. 

Finally, not to press a debatable principle to its utmost limits, I will 
only add, that neuralgias, and many irritations and oppressions of the brain 
and nervous system, unattended with pain, appear to be insidiously gene- 
rated by the same influence ; in illustration of which I may introduce the 



152 THE PRINCIPAL DISEASES OF THE 

following statement, made out from memoranda handed me by a gentleman 
in this city. 

Mr. N. L., who had, for many years, resided in the eastern part of the 
city, near the junction of Deer Creek with the Ohio River, and, conse- 
quently, in what is called a malarial atmosphere ; became affected with dys- 
pepsia, from which he had been exempt through the earlier period of life, 
when that disease generally occurs. His feelings became depressed and 
irritable, his strength declined, and he gradually lost much of his flesh. At 
length, under a full and nutritious diet, and the daily use of wine or brandy, 
those symptoms were removed; and he recovered his cheerfulness, strength, 
and flesh. Some time afterward, however, he began occasionally, to expe- 
rience, in the night, the premonitory feelings of a paroxysm of dyspepsia, 
succeeded in the morning, by vertigo, and a momentary loss of conscious- 
ness, followed by transient perspiration. These fits usually returned several 
times for a day or two, when a slight diarrhoea would supervene, and termi- 
nate the attack. After seven or eight months, it struck him that the dis- 
order had been recurring at regular periods j whereupon he determined to 
record the times of future returns, and soon found the periods to be, invari- 
ably, of thirty days. Becoming familiarized to them, and being a man of 
talents, and observation, he noted, that every paroxysm was ushered in by a 
peculiar vision of the mind, so that, at length, he would exclaim, i there is 
the same strange idea/ but the instant it was gone, i he never could have 
the least recollection of what it was/ This continued for more than a year. 
Medicines then checked the paroxysms for one or two monthly periods, when 
it recurred, as severe as before every twenty-one days, and continued at 
that rate, for five or six months; when, under the use of medicines, the re- 
currence came to be on the sixteenth day, the violence of the fit remaining 
the same. Throughout the second night after the access of the paroxysm, 
he would invariably lie awake, but was calm in mind, and without fever. 
For more than two years, he continued to note the recurrences of the fit, 
and found them constantly on the sixteenth day. During that period, as 
soon as the paroxysm was gone, he felt well, and his mind was clear and 
active j but gradually, it became so enfeebled and gloomy, that he made no 
further records. After about five years the fits began to abate in violence ; 
and to become irregular in recurrence, sometimes not returning for six 
weeks. At the present time, when he is sixty-five years of age, they still 
recur, but with great mitigation. He is never kept awake through the 
night, nor does he any longer lose his consciousness. His health, is other- 
wise good, and no impairment of memory or intellect seems to have been 
produced. 

III. Consequences of Autumnal Fever. — The reader will perceive, 
that a distinction is made between the lowly developed effects of the agent 
which produces autumnal fever, and the morbid states or consequences 
which follow it. As an illustrative contrast, I may anticipate what must 



INTERIOR VALLEY OF NORTH AMERICA. 153 

be repeated hereafter, and say, that yellow fever, even when not skilfully 
treated, leaves but few vestiges behind. Death, or sound, even improved, 
health, is the fate or fortune of the patient. It is far different with the 
subject of autumnal fever. When combated with skill, in its early stages, 
his recovery, it is true, may be perfect, and this in mild remittents, may be 
the case, if no medical aid be administered; but no fact is better established 
than that many cases are followed by consequences, from which patients 
slowly recover, or finally die. Some of these lesions are found in the in- 
nervation ; and manifest themselves as neuralgias in various parts of the 
body ; others exist in the blood, which remains impoverished ; others in the 
exhalent and absorbent vessels, generating dropsies ; others in the stomach 
and bowels, originating dyspepsia, diarrhoea, or constipation ; others in the 
liver, which may remain torpid or inflamed, with an attendant jaundice; 
lastly, others in the spleen, left inflamed or enlarged and softened. These 
various secondary and tertiary lesions, must be studied, to complete the 
pathological and therapeutic history of the Fever; and to them we must 
now give attention, beginning with the most frequent and formidable, — the 
disorders of the spleen. 



CHAPTER XI. 

CONSEQUENCES OF AUTUMNAL FEVER. 



SECTION I. 
DISEASES OP THE SPLEEN — GENERAL VIEWS. 

I. It is, I think, an unquestionable fact, that a vast majority of the people 
of this country, if not of our race, live and die, without experiencing any 
disease of the organ we are now considering. Abuses of diet, which carry a 
morbid condition into the alimentary canal, liver, kidneys, heart, and brain, 
do not, as far as we know, often disturb the spleen. Alcoholic potations, 
which light up inflammations in the same organs, and above all in the liver, 
leave the spleen unaffected. Vicissitudes of temperature, which inflame all 
the pulmonary tissues, the peritoneum, and the joints, are not known to oc- 
casion splenitis. All the viscera enumerated, may, moreover, be inflamed, 
or otherwise diseased, without necessarily carrying into this deeply caverned, 
and unsocial organ, any recognised, sympathetic disturbance. 

This exemption, from the sinister influence of many external and patholo- 
gical causes, may, perhaps, be ascribed, in part at least, to the following 
causes : — 

1. The organ is placed more beyond the influence of external agents than 



I 

154 THE PRINCIPAL DISEASES OF THE 

any other abdominal viscus, except the pancreas ; which, at the same time, 
it maybe remarked, is still more exempt from disease than the spleen. The 
spleen is also more secluded from outward influences, than the lungs, heart, 
and brain. 

2. Its tissues are few and simple, consisting chiefly, of arteries, veins, a 
fibrous, or cellulo-fibrous membrane, containing a red pulpy matter, and an 
external fibro-serous tunic. Now the simpler the structure of an organ, 
ceteris paribus, the fewer are its diseases. 

3. The few nerves which enter it, upon the vessels, are derived from the 
system of the great sympathetic, and do not bestow on it much animal sensi- 
bility; nor establish between it and the other organs of the body any lively 
sympathy. 

4. Compared with most of the organs, its function is, manifestly, more 
simple than theirs. What that function is, we do not know ; but it is, evi- 
dently, limited to the blood ; which it is either designed to receive and re- 
tain, from the other organs in certain excited states of the circulation, as sug- 
gested long since by Dr. Rush ; or it works out some change in the con- 
stitution of that fluid, or both ; functions, especially the former, requiring 
far less complication of structure, than the office of the liver, lungs, or 
brain. 

II. I shall not stop to inquire into the relative influence of these different 
anatomical and physiological reasons for the comparative exemption of this 
organ from original disease ; but proceed to remark, that while this exemp- 
tion is a fact, that must be admitted, there are three forms of fever which 
carry disease into that organ. I say three forms, for all fevers do not. Thus, 
most or all of the phlegmasise, may run on with extreme violence for many 
days, or in a subacute grade, for weeks, without occasioning disorder of the 
spleen; while on the other hand, two of the forms of fever to which I allude, 
very often, and the third, almost constantly, affect it; they are yellow, 
typhus, and autumnal fever. 

1. Dissections have shown, that the spleen is sometimes enlarged and 
softened in yellow fever, but these lesions are not even so frequent as in 
typhus and autumnal fever. 

2. The typhoid fever of the French writers occasions derangement of the 
spleen, as one of its most common characteristics. They are not generally 
known, however, during life, though sufficiently manifest after death. They 
have not only been observed in Paris, but in various parts of the United 
States. They consist of enlargement and softening, without, in most cases, 
many of the more common and certain signs of inflammation; neither pus 
being found within, nor coagulating lymph without the organ. The variety 
of fever, properly denominated typhus, also presents us, in fatal cases, 
with lesions of the spleen, though less frequently, and strikingly, than the 
typhoid. 

It is worthy of remark, that yellow and typhus fevers, do not, in cases of 



INTERIOR VALLEY OF NORTH AMERICA. 155 

recovery, leave behind them, as consequences, either splenitis or enlargement 
of the organ ; showing that they affect it differently from autumnal fever. 
I have never yet seen an enlarged spleen, following on any form of typhus. 
There is nothing then, to be said as to the treatment of diseases of the spleen, • 
consequent on these continued fevers. 

3. The great source of diseases of the spleen, in this country, is well known 
to be autumnal fever. In the present state of our knowledge, it would, per- 
haps, be most proper to content ourselves with the knowledge of this con- 
nexion, as a fact, and not attempt to speculate upon it. Nevertheless, it can 
do no harm to review the suggestions which have been made, if we do not 
rest any treatment upon a mere hypothesis. 

a. It has been conjectured, that autumnal fever commences in the spleen ; 
whence a morbid action spreads itself throughout the organism. But if this 
were the case, we ought to find that organ diseased before any other ; which, 
as far as we can judge by symptoms, is not the case. As remittent fever, 
moreover, is generally more violent and dangerous than intermittent, the 
signs of disease in the spleen should be more decided in the former than the 
latter ; which we all know is precisely the reverse of the fact. Finally, the 
manifestations of splenic disease, are often greatest on the decline of the 
Fever, which is directly opposed to what should be the case, if the Fever 
arose from the disease of that organ. 

b. It has been conjectured, that in these fevers, the spleen becomes involved, 
during the cold stage, from a recess of the blood from the exterior parts of 
the body, and its accumulation in the portal circle. Such a destruction of 
the equilibrium of the circulation, must be admitted as a pathological fact \ 
and that it is the cause of the disorders of that organ, may be inferred from 
another fact, which is, that remittents, in which the cold stage is less violent 
and protracted than in intermittents, disorder the spleen much less than the 
latter. On the other hand, however, typhoid fever injures the spleen fre- 
quently and seriously, although it be a continued fever ; and, of course, is 
exempt from those periodical revulsions, which characterize intermittents ; 
and hectic fever, attended with protracted diurnal chilliness, continues for a 
long time, without occasioning disease of the spleen. 

c. A third hypothesis, is, that malaria, or whatever may be the remote 
cause of autumnal fever, has a specific tendency to act on the spleen ) just 
as the remote cause of typhoid fever directs its influence on the glands of 
Peyer, and the remote cause of plague, on the ganglia and other organs of 
the axilla and groin. I think it can scarcely be doubted, that this is a 
reality. For, First. The great frequency of splenic disorders in autumnal 
fever, would seem to prove it. Second. The influence of the sulphate of 
quinine, in removing some of them, looks to the same conclusion. Third. 
In paludal districts, the spleen sometimes becomes disordered, by the slow 
or feeble action of some agent, the individual never having had an attack of 
either intermittent or remittent fever. 



156 THE PRINCIPAL DISEASES OE THE 

d. It is well known, that diseases of the spleen are almost incurable 
while the individual continues to reside in the locality which generated 
them ; but are curable, and sometimes spontaneously cease, when he seeks 
\ a more salubrious residence. 

On the whole, we may, perhaps, combine two of these hypotheses and 
say, that the spleen is not only engorged during the cold stage, but that it 
is the nature of the remote cause of autumnal fever, to determine a morbid 
influence on that organ, more than any other; and hence the frequency of 
its disorders in autumnal fever. We must not, however, lose sight of the 
fact, that we are entirely ignorant of the function, which is performed by or 
in the red pulpy matter of the spleen; that we know nothing of the rela- 
tions which it bears to the blood ; nor of the influence of the remote cause 
upon the blood ; and, therefore, that the disorders of the organ may, possi- 
bly, be induced through those humoral elements. 

In persons of strumous habit, the spleen is apt, like almost every other 
organ, to become the seat of tubercle ; but passing this by, we may say, 
that almost every case of disease of that viscus, known to us in this country, 
grows out of autumnal fever ; and, in what I shall say through the remainder 
of this section, I propose to limit myself to its disorders consequent on that 
fever, most of which, moreover, connect themselves with the intermittent 
form. 

III. Simple intermittents, if protracted, scarcely ever fail to disorder the 
spleen. Such disorder at first shows but few signs of an inflammatory cha- 
racter, presenting nothing but enlargement; but, in the succeeding winter, 
under vicissitudes of temperature, inflammation may be superadded. Of the 
true nature of this simple enlargement, we know nothing very positively ; 
but it must consist, I think, either in an increase of the peculiar pulpy mat- 
ter of the organ, with increased development of the fibrous structure ; or 
the accumulation and stasis of the blood, or both. To the former, only, 
should the term hypertrophy be applied. The latter is a species of perma- 
nent erection, and I presume it is by far the more common of the two. I 
once supposed it might sometimes be a hydropic condition of the organ, or 
a secretion of serum into the cells of the spleen, where it would be colored 
by the red pulpy matter; but can cite no facts in support of this conjecture. 

During the paroxysms of a malignant intermittent this organ suffers 
severely. This is proved by two facts. First. Those who recover are often 
left with enlargement of the spleen, although they might have had but two 
or three paroxysms. Second. The organ in those who die, is almost always 
found more or less swollen, greatly softened, and sometimes almost diffluent; 
but it rarely exhibits any acknowledged vestiges of inflammation. 

Inflammatory intermittents generate most of the cases of splenitis with 
which we meet. This inflammation may be accompanied by manifest swell- 
ing of the organ, or exist without it — it may, again, be either serous or 
parenchymatous. It may invest the organ with bands of lymph ; or fill it 



INTERIOR VALLEY OF NORTH AMERICA. 157 

with factitious tissue, thereby hardening it ; may soften it in the absence of 
such tissue ; or may end in suppuration. It may manifest itself, during the 
Fever, as a decided complication, and cease with it; or, escaping observation 
in the midst of the general overthrow of the functions, may attract our at- 
tention, for the first time, when the patient has begun to convalesce. In 
whatever stage of the Fever, or the convalescence, it may be developed, its 
diagnosis is essentially the same. This, when enlargement and inflammation 
are combined, is comparatively easy ; but when inflammation exists without 
enlargement, the diagnostic difficulty is sometimes considerable. 
We come now to consider the symptoms and treatment of splenitis. 



SECTION II. 

SPLENITIS. 

I. Symptoms. — These, as they occur during an attack of inflammatory 
intermittent fever, have been stated on page 66, Vol. II, and therefore, a 
brief recognition will, now, be all that is necessary. The characteristic symp- 
toms are pain, not often very acute, in the left hypochondrium ; tenderness 
or soreness on pressure, over the intercostal spaces, or below and behind the 
cartilages of the ribs ; frequently, a hacking cough ; a sense of oppression 
and anguish in the region of the diaphragm ; sometimes a hiccup — two 
examples of which were mentioned to me, as occurring iu their practice, by 
Drs. Henry and Merriman, of Illinois ; in violent cases, a pain in the left 
shoulder, of which, Professor Gross* has met with one example ; and I 
have myself seen two or three ; finally, more or less fever, according to the 
degree of inflammation. To complete the diagnosis, the absence of several 
symptoms, must be noted. The stomach and bowels are much less affected 
in splenitis, than in hepatitis ; there is no expectoration, and the respira- 
tory murmur, can be heard over the splenic region ; but when the organ is 
enlarged, which is almost invariably the case, there is a dull sound under 
percussion; finally, the patient can lie on the opposite side, much better 
than in hepatitis. 

II. Morbid Anatomy. — Splenitis may be either capsular or parenchy- 
matous. I know of no distinguishing symptoms ; but, from analogy, we 
may presume, that the former variety is accompanied by greater pain and 
tenderness, than the latter. The effect of the first, is to throw out coagu- 
lable lymph; which more or less invests the organ, producing, by its con- 
traction, deformity and, sometimes, atrophy of that organ, examples of 
which I have seen in the Louisville Hospital. The effect of the second, in 
some cases, is induration of the organ from infiltrations of lymph ; in others, 
softening, or suppuration. 

Occasionally, the spleen becomes adherent to the diaphragm ; the inflam- 

* Pathological Anatomy, Second Edition, p. 677. 



158 THE PRINCIPAL DISEASES OF THE 

mation may then permeate the latter, and enter the pleura and lungs, which 
will attach themselves to it above. Thus, splenitis, diaphragmitis, pleurisy, 
and pneumonia, may finally co-exist ; and, if the physician should not be 
called till the last is established, he might pronounce it the only disease. 
This extension of the inflammation to the diaphragm, explains the produc- 
tion of cough and hiccup, in splenitis 5 and affords a beautiful example of 
the influence of an inflamed surface, in exciting its own morbid condition 
in another surface, with which it is in contact. 

III. Exciting Causes. — The cases of splenitis now under consideration, 
are those which follow on autumnal fever, especially inflammatory intermit- 
tents. Beginning in the early stages, the inflammation may survive the 
cessation of that fever ; but in other cases, the organ is only brought into 
a state of sanguineous engorgement by the Fever, and the inflammation is 
awakened by an exciting cause. This is generally one of those sudden 
changes of weather, which are so frequent in our middle and higher lati- 
tudes, where it is more common than in the South. Being thus awakened, 
it generally occurs late in autumn, and through the following winter. But 
violent exercise may start the inflammation, when the organ is in a state of 
congestion. Lastly, an accidental blow or a fall, on the left side, may bring 
out the same result. 

IV. Treatment. — The fever which accompanies splenitis, very com- 
monly displays a remitting type ; and this paroxysmal character has often 
restrained the physician from active antiphlogistic measures, when they 
were imperatively demanded. In our warmer climates it may not be admis- 
sible, in most cases, to employ the lancet j but, in the cold and variable, 
venesection is indispensable ; the blood is sizy, and much relief follows its 
detraction. A case in the Commercial Hospital, of this city, during the 
present winter, required no less than four bleedings, after each of which the 
symptoms were mitigated; and the swelling of the organ, which was so 
great as to cause a bulging out of the cartilages of the ribs, was, also, dimi- 
nished by every operation. In mild cases, and especially, when the consti- 
tution is much broken down, cupping over and below the ribs, may answer 
the end proposed by the loss of blood ; after which the counter-irritation 
of a large blister will be useful. In acute cases, calomel, in two-grain 
doses, may be given every two hours, for a few days, the bowels having been 
previously evacuated, or, in its stead, active cholagogue and hydragogue 
purging may be effected by the compound power of jalap, infusion of senna 
with sulphate of magnesia, or pills, composed of calomel or blue mass, com- 
pound extract of colocynth, and squill, in equal parts. In the South, how- 
ever, and, in very paludal localities further north, these medicines must be 
administered with some reserve. At a comparatively early period, the sul- 
phate of quinine is demanded. At first it should be given in combination 
with nitrate of potash or muriate of ammonia, in the proportion of five grains 
of the former to fifteen of the latter; but, as the inflammation declines, 



INTERIOR VALLEY OF NORTH AMERICA. 159 

opium, in the quantity of half a grain or a grain, may be substituted for 
the latter, under which treatment the swelling and inflammation will, in 
general, rapidly abate. 

Subacute splenitis is often attended with fever, and the local symptoms 
are such as to suggest a mild inflammation. Such cases do not require the 
lancet, but cupping will always be proper. As to the remainder of the 
treatment, it should be a diminutive of that for the acute form. 



SECTION III. 

SUPPURATION OF THE SPLEEN. 

Parenchymatous splenitis frequently terminates in suppuration. A 
want of acute sensibility in the interior structure of the organ prevents a 
degree of pain sufficient to alarm either the patient or the physician ; and, 
in many cases, the fever is inconsiderable, and hence the inflammation is 
left to pursue its course. I once supposed hepatic abscesses commoner than 
splenic; but more extensive inquiries have shown me the reverse. In my 
intercourse with physicians, I have collected the following facts :— 

Dr. Flournoy, of Lexington, Missouri, has met with two cases. The pus 
was discharged into the bowels. In one, when the patient continued in a 
recumbent posture for some time, a swelling in the direction of the left 
hypochondrium would manifest itself; on pressing which, the flow of pus 
into the bowels could be heard ; and, in a few minutes afterward, there 
would be a discharge, per anum, of that fluid — the tumor having disap- 
peared. The patient seemed every way convalescent, when, from indulging 
in a large meal of meat ; fever and " colicky pains" supervened, and he died 
in two days. A hasty post-mortem inspection showed, in place of the 
organ, only a small sac ; the aperture from which into the bowel, no doubt 
the colon, was not found. 

The other case was marked by this peculiarity. A tumor formed; a dis- 
charge of pus took place from the bowels, and the swelling abated ; the dis- 
charge from the bowels ceased, the swelling rose higher than before, pointed 
externally, was opened with the lancet, and several ounces of pus escaped, 
after which recovery took place. 

Dr. Twyman, of St. Charles, in the same State, has seen two cases of 
splenic suppuration. One occurred in a child, three years old, and the dis- 
charge was into the bowels. In the other case, the abscess pointed exter- 
nally, and was opened below the cartilages of the ribs — both recovered. 
The Doctor has been informed of another in the neighborhood of St. Charles, 
which terminated in the same manner with the last. 

The following case was given me by Dr. Henry, of Springfield, Illinois. 
Although the subject of it lived in a region where autumnal fever abounds, 
he was not known to have had that disease. He was a robust man, who 



160 THE PRINCIPAL DISEASES OF THE 

had been subject for several years, to attacks of what was called colic; when 
in the winter of 1842-3, immediately after one of them a painful swelling 
rose rapidly in the left hypochondrium for which his physician bled him 
once, and purged him. The cathartic operated kindly but afforded no relief. 
After a while, Dr. H. was called in and found the left side of the abdo- 
men much enlarged, and both sides tense and tender. A fluctuation was 
obscurely perceptible on the splenic side, and the attending physician was 
treating him for ascites. He had a considerable degree of dyspnoea, a dry 
hacking cough, and would ' hiccup by the hour/ His stomach had been irri- 
table, but was not so at that time. Every morning, he had a slight chill, 
for which his physician had administered sulphate of quinine. Dr. H. did 
not advise any active treatment, but rather to wait and watch the progress 
of the disease. In a month, a sudden and copious discharge of pus and 
blood, came on from the bowels, with subsidence of the swelling ; and a 
perfect recovery followed. 

Dr. Boone, now of Chicago, Illinois, saw, at Hillsboro', in that State, a 
case of splenic abscess following an intermittent fever, which pointed ex- 
ternally, was opened, and the patient recovered. 

Dr. Christian, of Memphis, Tennessee, met with a case, preceded by in- 
termittent fever, in which the organ was greatly enlarged, and an abscess 
pointed in a mammary form on the left side of the navel. It opened spon- 
taneously, and discharged, at least, two quarts of pus, after which the patient 
recovered. 

Dr. Shanks, of the same city, saw two cases, in which an accidental blow 
given to the spleen, when enlarged from intermittent fever, brought on sup- 
purative action, with a discharge of pus by the bowels. Both the patients 
died ; but no post-mortem inspection was made. 

Dr. Frazier, of the same place, related the following : A river-man, who 
had been often affected with intermittent fever, suffered an injury of the 
ankle, which rendered amputation necessary. Two weeks after the opera- 
tion, he died. On examination of the body, an abscess of the spleen, with- 
out any enlargement of the organ, was found. The character of this case 
is ambiguous, and the pus might have been, and probably was, absorbed 
from the stump and deposited in the spleen — an example of the cold abscess, 
of the surgeons. 

Of these eleven cases, the discharge of pus in six, was by the bowels ; 
in three externally ; in one by both modes ; and in one no evacuation took 
place. 

It deserves remark, that none of the abscesses made their way into the 
stomach, peritoneal cavity, or lungs. It should likewise be noted, that the 
discharge of pus was not followed by hectic fever ; and that all the patients 
recovered except one, who fell a victim to the indulgence of his appetite 
during convalescence; and two, who had suffered external injury. Lastly, 
all the cases occurred north of the thirty-fifth degree, and most of them 



INTERIOR VALLEY OP NORTH AMERICA. 161 

above the thirty-eighth. Not one case was mentioned to me south of the 
former parallel of latitude ; and hence, we may conclude, that suppuration 
of the spleen is a northern rather than southern disease ) we are also ad- 
monished, by the issue of two cases, that those who have enlargement of the 
organ, are in danger from mechanical injuries. 

The treatment of suppuration of the spleen, after the discharge of pus 
has commenced, must, of course, be restorative, and consist of nutritious 
diet (all inordinate indulgences being avoided) • the bark, rendered still more 
necessary than in ordinary suppurations, from the peculiar diathesis of the 
patient ; elixir of vitriol, in combination with that medicine ; the blue pill, as 
an aperient, when one is required ; opium, especially at night, and flannel 
next the skin. 



SECTION IY. 

ENLARGEMENTS OF THE SPLEEN. 

I. By enlargement of the spleen we are not to understand the swelling 
which accompanies splenitis, which may be inconsiderable, especially when 
the inflammation is serous. The enlargement which now occupies us, may 
exist independently of inflammation, and certainly does not arise from it. 
The same pathological cause which produces enlargement, may also gene- 
rate inflammation ; but, in many cases, it does not; in all, however, it so pre- 
disposes to that disease, that slight exciting causes may bring it on. In- 
flammation is, then, a contingent of enlargement. Now and then it is acute, 
and may, perhaps, prove fatal; but I have not witnessed such a termination. 
More commonly, however, it assumes a chronic form, or returns at irregular 
intervals in a subacute grade. 

II. Enlargements of the spleen are spoken of, by some pathologists, as 
hypertrophies. But this is a misapplication of the term. The augmenta- 
tion of size, which can be brought about, in a few days, by a pathological 
cause, cannot, with propriety, be called an increase of growth. As well might 
we call anasarca, an hypertrophy of the cellular membrane. The spleen is 
undoubtedly a peculiar variety of erectile tissue ; and when it becomes sud- 
denly enlarged, we are bound to regard the material which gives it distension 
as blood. It may be alleged, however, that it is not blood, but an increase 
of the peculiar, pulpy matter, which at all times fills the areolar structure 
of the organ ; but it seems contrary to analogy, that a pathological condi- 
tion should augment the product of the healthy function of an organ. The 
rapid reduction, in bulk, which recent enlargements of the spleen sometimes 
undergo, is another argument for the theory of simple congestion and stasis. 
If the contents of the splenic sac be examined, when the organ is in such 
a state, we of course, have a mixture of black or stagnant blood, and the 
peculiar pulp of the organ, with its Malphigian corpuscles. Under this exces- 

VOL. II. 11 



162 THE PRINCIPAL DISEASES OF THE 

sive distension and immersion, for some time, in the same blood, the internal 
fibrous structure will, of course, lose much of its cohesion ; and the whole 
substance of the organ, when its capsule is penetrated with the finger, be 
found almost as tender as a coagulum of blood ; and this, as we have seen, is 
the condition of the organ in many who die of autumnal fever. 

III. But enlargement very commonly remains long after the fever, which 
occasioned it has been cured. On what then does it depend ? Doubtless, 
in some cases, it depends on the coagulation of the blood, whereby its 
fibrinous portion, in detached or adherent filaments, is mingled with the 
more fluid portions; and, sometimes, on the infiltration of coagulating 
lymph, from subacute, parenchymatous inflammation ; giving increased 
density to the organ, and rendering its reduction to the original size an im- 
practicable undertaking. But, in most instances, it would seem there is 
nothing more than a loss of contractility in the areolar and vascular tissues, by 
which it continues to receive and contain a large quantity of blood, as in 
the following — 

Case. — Dr. Hurlbert, of Ottawa, Illinois, in the year 1838, was called to 
see an Irish immigrant, who had been a soldier in the West Indies ; while 
there he suffered from intermittent fever, and the enlargement of the spleen 
which followed, had continued for fifteen or twenty years. The organ pro- 
jected across the abdomen to the right iliac region. When the Doctor 
arrived the patient had high fever, with hard pulse, abdominal tenderness, 
pain in the left hypochondrium, irritable stomach and some difficulty of 
breathing — in short, labored under acute splenitis. He was bled five times, 
blistered, and took freely of calomel and diaphoretics, which subdued the 
inflammation. During his convalescence, the swelling of his spleen began 
to abate ; and two years afterward, when the Doctor saw him, it was entirely 
gone. It can scarcely be suppposed that this reduction would have taken 
place, if the organ had been hypertrophied or indurated, for fifteen or twenty 
years. 

IV. I have already referred to two cases of suppuration, in enlarged 
spleens, from blows on the left hypochondrium. It remains, now, to add, 
that such violence may occasion a rupture of the organ, and the consequent 
death of the patient, as appears from the following — 

Case. — An Irishman who had labored on the canal, between Lake Michi- 
gan and the Illinois Biver for a twelve month, during which he had expe- 
rienced several attacks of intermittent fever, came to Peoria, Illinois, in a 
state of emaciation, but with a tumid abdomen. His complexion was of a 
greenish-yellow tint; while the whites of his eyes showed a bluish tinge. 
In a quarrel he received a kick on the region of the spleen, which he sur- 
vived four days. Dr. Dickinson and Dr. Tucker made a post-mortem 
examination. The intestines were adherent from recent inflammation. 
The spleen was six or seven times its usual size; some parts of it were in 
a state of induration, and of a greenish-yellow color ; others were softer and 



INTERIOR VALLEY OF NORTH AMERICA. 163 

darker. It was ruptured, and a quantity of blood had escaped into the peri- 
toneal cavity. 

But the rupture may be spontaneous, as appears from the following — 

Case. — A patient of Dr. Cross, in the same town, had intermittent fever 
for eight or ten days, from which he recovered. About a month afterward, 
be was attacked with ague, of which he had several relapses. On a cer- 
tain morning, while walking about, he was attacked with a chill, followed 
by fever. He took a cathartic, and on rising, during the hot stage, he 
fell down and expired. Twenty hours after death, his body was examined. 
The spleen presented a large circular and ragged aperture ; and was so ten- 
der that it could not bear its own weight. About a gallon of blood, taking 
that which had already escaped into the peritoneum, with what was forced 
out by compression, made the quantity which the organ had contained. 

Y. In its early stages, enlargement of the spleen may be detected by dul- 
ness of sound, on percussion, over the false ribs of the left side, the respira- 
tory murmur of that region being unaltered. But, that this sign may lead 
to a false diagnosis, I was lately taught by the subjoined — 

Case. — I was called into consultation by Dr. Dodge of this city, on a 
patient who labored under cerebral inflammation, of which he died. In 
attempting by percussion and auscultation, to ascertain whether his disease 
might not be complicated with pneumonia, we found a manifest dulness 
over the left hypochondriac region ; but the respiratory murmur was en- 
tirely normal. We, of course, concluded that, from an attack of autumnal 
fever at some former period, he had an enlargement of the spleen, though 
not great enough to project below the ribs \ but to our surprise, on examining 
the body after death, we found the left lobe of the liver so hypertrophied, 
that it was jammed against the spleen, which had its natural size. 

After the tumor has advanced below the cartilages of the ribs it cannot 
be confounded with any other swelling except that attendant on suppura- 
tion of the kidneys, from which it may be distinguished by the previous 
history. 

The subject of enlarged spleen is, generally, more or less emaciated in his 
limbs, while his abdomen is tumid. His complexion is wan ; yellowish, but 
less so than in affections of the liver ; indistinctly greenish, or chlorotic, 
dirty leuco-phlegmatic ; or, finally, that of cancerous cachexia. The whites 
of the eyes have not the sallowness produced by liver disease. This change 
of complexion deserves to be taken into account in our investigations into 
the functions of the spleen. Is it probable that the organ exerts any 
influence on hsematosis ? That the blood is in a pathological condition, 
cannot, I think, be doubted ; not only from the altered complexion 
of the patient, but from the hemorrhages from the stomach and bowels, to 
which he is liable. I knew a gentleman with enlarged spleen, who had two 
copious hemorrhages of this kind ; and a number of our physicians have 



164 THE PRINCIPAL DISEASES OF THE 

witnessed the same thing. As illustrating this assertion, and showing, at 
the same time, two other interesting facts, I will cite a case given me by 
Dr. Wallace, of Akron, Ohio. 

Case. — A man experienced an attack of remittent fever, with relapses, in 
an intermittent form, and was severely salivated. There followed on this 
treatment, so great a susceptibility to the action of all mercurial prepara- 
tions, that for years afterward, he could detect the smallest quantity, admi- 
nistered to him, by the constitutional irritation, morbid vigilance, and diar- 
rhoea, that would inevitably follow. When exposed to a cold and damp 
atmosphere, his spleen would suddenly swell, so as to bulge out below his 
ribs; and in the course of the following night, under the influence of opium, 
and diaphoretics, it would recede. He was never without tenderness in the 
splenic region ; but had no dropsy. He used iodine with some benefit, but, 
while his health seemed to be gradually improving, he died, suddenly, of 
hemorrhage from the stomach and bowels. 

Of the influence of enlarged spleen, in favoring relapses in intermittent 
fever, I have already spoken. Some patients have observed, that active 
exercise was followed by a return of the Fever. The connexion between this 
affection of the spleen, and dropsy, will be considered, in another section. 
In many cases, the appetite of the patient, and his digestion, are very tolera- 
ble; and he regards his "ague-cake," as a mere inconvenience. In some in- 
stances, however, it becomes a burden, for it may extend into the right iliac 
region, and rest upon the brim of the pelvis. In general, the enlarged 
spleen does not leave its position ; but, a short time since, Dr. Moffit, one 
of the house physicians of the Commercial Hospital, in this city, called my 
attention to a patient, who some years before had suffered from intermittent 
fever, in whose abdomen there was a hard, spleniform tumor, three or four 
times the size of the spleen, which could be moved to any part of the abdo- 
men, though it inclined to the left side; and could be nothing else, I think, 
but that organ in a state of dislocation. 

VI. Treatment. — When the symptoms of splenitis are present, the ap- 
propriate antiphlogistic treatment, must be first employed; under which the 
enlargement sometimes rapidly diminishes. But the majority of cases do 
not thus.yield ; and then the practice becomes in a great degree empirical, 
consisting of various therapeutic agents, which we must consider, seriatim. 

1. An occasional emetic is beneficial. It agitates the affected organ, and 
thus promotes the circulation of its stagnant blood ; increases the activity of 
the absorbent vessels ; determines to the surface of the body ; and prepares 
the stomach for the reception of other medicines. But the loss of density 
and strength, in the capsule and fibrous texture of the spleen, is sometimes 
so great, that in vomiting, a rupture might occur ; and, therefore, emetics 
should not be ordered, without care and circumspection. 

2. Cathartics are not liable to that objection; and, those which act as 
hydragogues, often prove beneficial. Care must be taken not to reproduce 



INTERIOR VALLEY OF NORTH AMERICA. 165 

the Fever, by continuing their action too long. One of the best is the com- 
pound powder of jalap with the bark. Another is a pill composed of one 
grain of blue mass, one of aloes, two of rhubarb, and a fourth of a grain of 
elaterium. Free purging may be effected with two or three of these pills ; 
and a single one will operate as an aperient. When the liver is torpid, and 
the discharges are not colored with bile, the elaterium should be omitted, 
and the quantity of blue mass doubled. 

3. Diuretics are frequently prescribed in this affection. They were pro- 
bably, at first, suggested by the dropsy which is often present. I am not 
certain as to their effects in my own practice, but have thought them bene- 
ficial. The following formula is as good as any other : — 

R. — Pulverized Squill, gr. xxiv. 

Nitrate of Potash, ----- gii. 

Mix intimately, and divide into twelve papers : one to be taken three 
times a day. When inflammation is present, this refrigerant diuretic will 
be peculiarly proper. In an opposite diathesis, or when the tendency to 
relapse is great, two grains of the sulphate of quinine should be added to 
the powder. 

4. The bar7c, combined with an equal quantity of cream of tartar, has 
often done good. Should this compound purge too much, the proportion of 
the latter must be diminished. 

But the sulphate of quinine has attained a higher reputation than the 
bark. It is peculiarly demanded in recent cases, while the original morbid 
diathesis still lingers in the system. When given in the declining stage of 
splenitis its effects on the enlargement, are, perhaps, more favorable than in 
any other condition. And this leads me to say, that when no inflammation 
is present, an occasional bloodletting, if the powers of the system should not 
be greatly reduced, will much increase the efficacy of the bark, quinine, and 
other bitters, stimulants, and alterants. Many physicians, who practise 
where malignant intermittents prevail, speak in high terms of quinine, in 
the splenic enlargements, which are so rapidly generated by that form of 
fever; but, I have not met with any, who had witnessed the instantaneous 
efiects which Piorry declares he has seen in the hospitals of Paris. When 
inflammation still lingers in the organ, the union of nitrate of potash with 
the quinine, is highly beneficial. Ten grains of the former, with five grains 
of the latter, may be given three or four times in the twenty-four hours." 
On the other hand, if the excitement be low, it will be proper to substitute 
for the nitre, five grains of Dover's powder. 

5. Iodine, from its promoting the absorption of goitrous tumors, has been 
extensively employed for enlargements of the spleen ; and was expected to 
act on the absorbent system. It has, undoubtedly, effected the object for 
which it was administered; but not so constantly as to meet the anticipa- 
tions under which it was at first prescribed. An extemporaneous formula, 



166 THE PRINCIPAL DISEASES OF THE 

consisting of iodine or its tincture, administered in a solution of the hydrio- 
date of potash, may be readily devised ; or the latter may be given alone, 
in quantities varying from half a drachm to two drachms in the day and 
night. 

In the hands of some of our physicians, bromine has proved useful ; but 
I cannot speak of it from experience. 

6. Referring to the impoverished or spansemic condition of the blood, 
chalyheates seem indicated. I have seen good effects from the proto-carbo- 
nate of iron, in combination with the bi-tartrate of potash ; but the best pre- 
paration, when properly made and preserved, is the iodide of iron. It may 
be presumed that the ferrocyanate of quinine would be efficacious in cases 
demanding a chalybeate, but I do not know that it has been employed. 

7. Counter -irritation j with blisters or antimonial ointment, is a common 
remedy. The former are to be preferred. To be of service, the plaster 
should be large. 

8. Throughout the whole treatment, the patient should be supported by 
nutritious diet, and have the excitement and perspiratory function of the 
skin maintained by stimulating baths, frictions, and the use of flannel. 

9. In many instances it is impossible to reduce the enlargement, while 
the patient continues in the locality where it originated ; and it has been 
known to disappear, without remedies, under a change of place. Thus, Dr. 
Echols, of Selma, Alabama, went to Lexington for the prosecution of his 
studies, while laboring under an enlarged spleen j and returned, in eighteen 
months, free from the disease, although he had discontinued all medicines. 

VII. Actual Practice of many of our Physicians. — I will now 
mention the modes of practice pursued by a number of physicians, beginning 
with the northern : — 

Dr. Conant, of Maumee, Ohio, treats subacute inflammatory cases with 
oil of turpentine, externally and internally. Professor Brainard, of Chicago, 
Illinois, uses the blue mass, sulphate of quinine, and extract of taraxacum, 
with blisters. Dr. Henry, of Springfield, in the same state, after trying 
iodine ointment, and mild mercurials, with some success, was led to employ 
the sulphate of quinine and the blue mass combined ; from which he ob- 
tained much greater benefits. Dr. Fry, of Peoria, in the state just mentioned, 
uses sulphate of quinine and sulphate of iron combined, keeping the bowels 
open with jalap or the extract of taraxacum. Has seen the hydrobromate 
of potash cure two cases, and do good in a third. Dr. Howland, of Ottawa, 
in that state, sometimes bleeds once ; but relies upon the external use of 
iodine, and the internal administration of extract of conium maculatum, 
sulphate of iron, and aloes, combined, and given in pills. Dr. Thomas, of 
Boonville, Missouri, has used muriate of ammonia with advantage. Dr. 
Hutchinson, of the same place, has cured the disease with blue pill and 
blisters. Dr. Flournoy, of Lexington, often bleeds in the beginning, then 
gives the muriate of ammonia, blue pill, and tartar emetic, combined, em- 



INTERIOR VALLEY OF NORTH AMERICA. 167 

ploying external irritants at the same time. Dr. Digges, of the same town, 
uses iodine and cutaneous irritation. He has tried the muriate of ammonia 
only in old cases, when it failed. Dr. Long, of Marshall, in that state, has 
found the sulphate of quinine beneficial. Dr. Price, of Arrow Rock, uses 
external irritation, and administers the hydriodate of potash, with aperients, 
internally. Dr. Christian, of Memphis, has used small doses of calomel or 
blue pill, with tartar emetic, and muriate of ammonia, followed by the bark; 
but has often found a change of locality indispensable to recovery. Drs. 
Shanks and Frazier, of the same city, have employed scarification and cup- 
ping, dry cupping, blistering, and the deuto-ioduret of mercury, externally, 
bitters and stimulating aperients, internally. 

Dr. S. B. Malone, of Columbus, Mississippi, blisters, applies a plaster of 
cicuta, and administers calomel and the sulphate of quinine. Dr. Searcy, of 
Tuscaloosa, Alabama, has found the following compound useful : 

R. — Sulphate of Quinine, - 1 , . 

Castile Soap, _____ j 

Aloes, ------ •* 

Rhubarb, ------ I each gss. 

Blue mass, ------ J 

Mix, and make into pills of the common size — one to be given three 

times a day. 

Dr. Guild, of the same town, bleeds, purges, and then administers quinine. 
Dr. Haywood, also of the same town, has found the disease to disappear 
spontaneously; but sometimes uses calomel and tartar emetic in small doses. 
Drs. Dancy, Parish, and Davis, of Greensboro', in the same state, have ob- 
served the spontaneous disappearance of the disease ; but, occasionally, pre- 
scribe blisters or tartar emetic ointment, and small doses of calomel. Dr. 
Echols, of Selma, treats it with cathartics and external liniments. Dr. 
Fearn, of Mobile, has used, successfully, the blue mass and rhubarb at 
night, with carbonate of potash and powdered mustard as diuretics, and the 
sulphate of quinine, with infusion of gentian, as a tonic. 

VIII. Concluding Remarks. — I find, on examining my notes, that in 
many instances, the treatment of enlargement of the spleen, was overlooked 
in my conversations with medical gentlemen ; but quotations enough have 
been made to show the state of medical practice among us, in that affection. 
On the whole, I am disposed to believe it more inflammatory and obstinate 
in the North, than the South; as well as more frequent in proportion to the 
number of cases of intermittent fever. In the warmer latitudes, the enlarge- 
ment seems to partake more of the character of simple congestion than in 
the colder climates. 

It has sometimes been supposed that a premature use of the bark con- 
tributed to the production of enlarged spleen. If this ever happened, it was 
because the lancet had not been adequately employed before resorting to that 
medicine ; which, from its tonic and stimulating qualities, may, at the same 



168 THE PRINCIPAL DISEASES OF THE 

time that it arrests the paroxysms of fever, contribute to disorder the viscera. 
Such an objection will not lie against the sulphate of quinine ; and the 
sooner the Fever is checked, the less is the danger of enlarged spleen ; as it 
is the repetition of the paroxysms, more than anything else, which pro- 
duces that organic derangement. Nevertheless, venesection, in the higher 
latitudes, is of great value, as a preparative of the system for the quinine ; 
and it is the omission of the lancet, which in many cases permits a result, 
that throws discredit on that medicine. 



SECTION V. 

DISEASES OF THE LIVER FROM AUTUMNAL FEVER. 

I. There is much in the symptomatology and pathological anatomy of 
our autumnal fever to raise and perpetuate, in our minds, the idea of a deep 
implication of the liver, much to justify the epithet " bilious, " so generally 
applied to them j which, indeed, would be a very convenient and appropriate 
term, if it could be so used as not to suggest the idea of their originating 
from some primary affection of the liver. All this implies that the biliary 
function is, in general, greatly disturbed in these fevers; which, we have 
already shown, both by the phenomena during life, and the appearances after 
death, to be the case. The proper treatment of the morbid conditions of the 
liver during the Fever has been already pointed out ; and we come now to 
inquire into its condition after the Fever has been arrested. In doing this, 
the first act which meets us is, that in many cases, the functions of the 
organ are natural and healthy from the termination of the Fever; the next, 
that when they are morbid, the liver appears in some cases to be free from 
inflammation, in others to be inflamed. We must study these conditions 
separately. 

II. Mere Functional Lesions. — 1. Torpor, or inactivity of the organ 
in its secretory or excretory function, appears, sometimes, to constitute the 
only morbid condition. I am disposed to believe that the liver is not, like 
the kidneys or the lungs, an organ which secretes continuously, but that its 
action is essentially intermittent. Its relations are with the stomach and 
duodenum, whose functions are periodical ; and the whole may be presumed 
to work, under the same law of intermittence. The universal habit of taking 
food at intervals, and the certainty with which digestion is impaired by the 
introduction of new aliment, while that previously taken is undergoing con- 
version into chyme, demonstrate that hunger and the functions of digestion 
are essentially periodical. That, while they may be modified by habit, they 
are the cause and not the effect of habit. The reason of this lies quite on 
the surface. If food were taken continuously, much of it would necessarily 
pass the pylorus undigested; and not having experienced the action of the 
stomach, could not be converted into chyle, and would be lost to the nour- 



INTERIOR VALLEY OP NORTH AMERICA. 169 

ishment of the system. The natural periodicity of the functions of the 
stomach being established, a corresponding periodicity, must be admitted in 
the functions of the duodenum. The chyme being prepared, the pylorus 
expands, and the stomach, changing its mode of muscular movement from 
a gestatory to a peristaltic or expulsive, pushes the alimentary mass into 
the supplemental organ, there to receive an impregnation of bile and pan- 
creatic juice ; after which the compound is to be transmitted to the small 
intestines for absorption into the system. Now it would be a physiological 
absurdity for the liver and pancreas to pour out continuous currents of se- 
creted fluid, when the ends for which they are formed can only be accom- 
plished at intervals. I conclude, then, that those organs, when the indivi- 
dual is in health, are stimulated into activity by the impress of food in the 
stomach, the excited state of which invites into the coeliac artery more 
blood than before; whereby more is sent through the liver by the hepatic 
artery, and especially by the vena porta ; and thus, it is not only roused 
into action by its nervous associations with the stomach, but by the in- 
creased supply of blood. The secretion of bile and pancreatic juice goes on 
with activity, under such circumstances; the excretory ducts become filled ; 
and, by the time the chyme begins to pass the pylorus, the currents of se- 
creted fluid are pouring into the duodenum, to mingle with it — secretion, 
then, giving place to excretion, to be revived on the next call of the 
stomach. If these physiological speculations be correct, it follows, that 
while the liver performs a continuous function of circulation in transmit- 
ting the blood of the vena porta, it executes a periodical function of secre- 
tion and excretion. 

Now an organ whose function is periodical is much more likely to fall 
into torpor or inaction, than one whose function is incessant. Hence the 
frequency of torpidity, or suspended secretion in the liver, and its con- 
tinuance in so many instances after attacks of autumnal fever. In this con- 
dition, the elements of the bile, which are developed in the blood, are not 
collected and combined in that organ ; and one of them, the coloring matter, 
manifests itself in the complexion, the urine, and the serum of the blood. 
In this manner, a variety of jaundice, more or less intense, may arise. But 
when the secretion of bile is not suspended, the excretion may be. The 
biliary ducts may not act with energy ; or duodenal inflammation or irrita- 
tion during the Fever, may have extended to the common gall duct and 
caused a thickening of its mucous membrane, or a spasmodic constriction ; 
which, remaining, may interfere with the excretion of the bile. In these 
pathological conditions, the sallowness may be even deeper than in the other; 
and in all, the stomach, from its sympathy with the liver and the bowels 
from the same cause, and also from the absence of their natural stimulus, 
the bile, soon show a variety of functional disturbances, such as anorexia, 
flatulence, acidity, constipation, or diarrhoea. As long as these conditions 
of the liver continue, the convalescence of the patient will be slow and un- 



170 THE PRINCIPAL DISEASES OF THE 

satisfactory ; his muscles of locomotion will be weak ; his heart feeble and 
irritated ; his nervous system morbidly sensitive, and his spirits gloomy. 
All this, I suppose, may exist without the slightest inflammatory affection 
of the organ; but it constitutes a good predisposition; and, if allowed to 
continue, vicissitudes of temperature, or some other cause, may, at length, 
excite inflammation. Let us now direct our attention to the removal of 
these functional disorders. 

III. The Remedies. — Before prescribing for the pathological conditions, 
the physician should, by his knowledge of diagnosis, ascertain that inflam- 
mation does not exist, when he may pursue the following method : — 

1. An active emetic is generally of signal service. Nothing arouses the 
liver to renewed secretory action, or emulges its ducts, more successfully. 
One of the best is an infusion of the root of the sanguinaria canadensis with 
ipecac. Tartarized antimony is too sedative ; and, if it be used, should be 
dissolved in some stimulating draught, as a tea of valerian root; an opiate 
to be given after the operation. 

2. An active cathartic should next be administered. If the patient should 
labor under diarrhoea, a large dose of calomel and rhubarb, followed by an 
opiate at night, will be proper. If costive, a portion of calomel at night, 
with infusion of senna the next morning, or a dose of pills, composed of 
equal parts of calomel, gamboge, and aloes, should be given ; and, after the 
operation, an anodyne. 

3. The patient may now be put upon the use, every night, of two or more 
of the following pills : — 

R. — Blue mass, - -\ 

Aloes, - - - - - - j- each gss. 

Ipecac, -_-__ J 

Extract of taraxacum, - - - gi ss . 

Mix, and make into thirty-two pills. 

4. In the day, as much tincture of rhubarb with gentian, as may be 
necessary to secure, with the pills, two or three alvine evacuations, should 
be administered ; or the pills being sufficient to keep up the action of the 
bowels; a cold infusion (made by displacement) of the bark of the wild 
cherry tree (Prunus Virginiana), may be substituted for the tincture, 
which will be especially required when there is stricture of the common gall 
duct — the prussic acid of the infusion, being well fitted to relieve that con- 
dition ; while it stimulates the patient into greater cheerfulness. 

5. Antacids will, in most cases, be required. The subcarbonated alkalies 
answer very well in ordinary cases ; but, if the bowels should be obstinately 
torpid, magnesia will be better; or, on the other hand, if diarrhoea be 
present, lime-water and boiled milk should be preferred. 

6. The region of the liver should be sponged, and the feet immersed, in 
a hot nitro-muriatic solution, and flannel should be worn next the skin. 



INTERIOR VALLEY OF NORTH AMERICA. 171 

7. The diet of the patient ought to be nutritious, savory, and stimulating, 
but moderate in quantity. 

8. He should be exhorted to take as much exercise as possible, on horse- 
back, or on foot, in the open air. 

9. Throughout the whole treatment, his nervous system will demand 
gentle narcotics and stimulants, especially at night, of which more will be 
said under the next head. 

By these means, the uninflammatory hepatic torpor, following our autum- 
nal fever may, in general, be soon removed. Let us now turn our attention 
to the inflammatory condition of the liver. 

IY. Subacute Hepatitis. — I. The acute inflammation to which the liver 
is liable, during the Fever, may remain in a subacute form, after that 
disease has been arrested ; or the organ being, at the close of the Fever, in 
a state of torpor or engorgement, inflammation, under the influence of ex- 
citing causes, may supervene. On the relations between subacute hepatitis 
and the Fever, of which it is a consequence, the following remarks may be 
made : — 

1. While, as we have seen, splenitis oftener follows intermittent than 
remittent fever, hepatitis is more frequently the effect of the latter than the 
former. It would be erroneous to say, that either is confined to a particular 
form of the Fever; but that each has a closer connexion with one than the 
other is, I think, certain. I cannot explain the more frequent occurrence 
of hepatitis than splenitis, in remittent fever, except it be, that a gastro- 
enteritis is oftener present in the former than the latter, and by continuity 
of mucous membrane, or sympathy, excites hepatitis. 

2. Of the relative frequency of these two affections, as consequences of 
autumnal fever, I cannot speak with statistical or numerical accuracy, but 
believe that the spleen suffers oftener than the liver. Slight degrees of 
inflammation may pass undetected in the former organ ; but, when seated 
in the latter, they manifest themselves in an obvious manner. Thus, it 
seems probable, from the number of known cases of splenitis, that if all 
were discovered, the catalogue would much exceed that of hepatitis, from 
the causes we are now considering. 

3. Of the relative prevalence of hepatitis, from the Fever, in the North 
and the South, I cannot speak positively; but inquiry has satisfied me, that 
there is quite as much of it in the former as in the latter, in proportion to 
the number of fever cases. 

4. Hepatitis, I think, is more apt to run into suppuration, in the southern 
than in the northern portions of the Valley. The number of hepatic suppu- 
rations, of which I have collected an account, is less than the number of 
splenic abscesses. A large majority of them were south of Memphis; the 
reverse of what is true in regard to abscesses of the spleen. Of the cases, 
the mode of termination of which I have ascertained, five, occurring in the 
practice of Dr. Drish, of Tuscaloosa, Alabama, discharged themselves through 



172 THE PRINCIPAL DISEASES OP THE 

the lungs ; one, a patient of Dr. Shanks, of Memphis, opened externally ; 
and one, mentioned to me by Dr. Vivian, of Dover, Missouri, took the 
direction of the bowels. Dr. Fearn, of Mobile, has had several cases, the 
termination of which I did not record. 

5. In estimating the influence of autumnal fever in producing hepatitis, 
we must not forget the effects of alcoholic intemperance in exciting or pre- 
disposing to that affection ; and thus causing it to occur more frequently 
than it would from the Fever alone. 

6. When at Memphis, Dr. Shanks took me to see a river-woman, who, 
after an attack of intermittent fever, had, at the same time, an enlarged 
spleen, and a suppurating liver which pointed externally. 

7. If hepatic abscesses, as appears probable, are more common in propor- 
tion to the number of cases of hepatitis, in the South than in the North, it 
follows that the inflammation is oftener parenchymatous in the former — 
membranous in the latter ; and this may explain the fact, that bilious ap- 
pearances are rather more conspicuous in the South than the North, while 
the number of cases of hepatitis is not greater. 

8. There are few inflammations more apt to recur than hepatitis. I know 
a lady in whom the disease followed autumnal fever, while she was still a 
child, that relapsed, at various times for the next thirty years ; several of 
the attacks being prolonged and violent. 

II. The symptoms of subacute or chronic hepatitis, are constipation or 
diarrhoea; a suspended, depraved, or increased secretion of bile; acidity and 
irritability of stomach; variable appetite; in general, a foul and yellowish 
tongue ; more or less jaundice of the skin and eyes, with yellowness of the 
urine ; tenderness, and sometimes pain in the epigastric and right hypochon- 
driac regions ; aching about the right shoulder, sometimes descending into 
the arm; inconvenience in lying on the left side; a hacking cough, without 
expectoration ; a dry, harsh, and insensible skin with coldness of the feet ; 
occasional flushes of fever, according to the degree of inflammation ; almost 
constant frequency of the pulse, with fits of palpitation of the heart; reduced 
activity of mind, whimsicality, despondency, irresolution, and fear of death. 
In addition to the direct sympathy of various parts of the body with the 
liver, they sympathize with the stomach, which is dyspeptic ; with the bowels, 
from which the liver withholds a due supply of bile, or irritates, with that 
which is unhealthy ; but, above all, the whole nervous system, and, indeed, 
all the tissues of the body, are irritated by the bile, or its elements, which 
float with the circulating currents, and act on the exquisitely susceptible 
interior membrane of the arteries. 

III. 1. In the treatment of the hepatitis following on autumnal fever, a 
copious bloodletting, in the higher latitudes, is, in some cases, indispensable, 
but there are very few patients that will bear its repetition ; and the greater 
number do not demand the lancet. The depressing influence of biliary 
matter, mingled with the blood, seems to be the reason why copious vene- 



INTERIOR VALLEY OF NORTH AMERICA. 173 

section is not supported in this inflammation ; but we must ascribe a part of 
the intolerance of this remedy, to the paroxysmal character of the Fever, 
which generated the inflammation. When general bleeding seems unadvisa- 
ble, cupping may be employed with advantage. 

2. The administration of small doses of calomel or the blue mass — I re- 
gard the former as preferable — should be continued to the extent of ten or 
twenty grains a day, until the mouth is slightly affected. If much fever be 
present and the stomach irritable, nitrate of potash may be advantageously 
combined with the calomel ; but when that organ is not specially involved, 
and the phlogistic action is considerable, minute doses of tartarized anti- 
mony or ipecac will prove beneficial. 

3. An occasional emetic or cathartic does good, by emulging the gall ducts 
— the inflammation being of a low grade — and, at all times, the latter will be 
proper, to keep up the peristaltic action of the bowels. 

4. In obstinate cases, nitric acid internally may be tried; and, in every 
stage and grade of the disease, the nitro-muriatic lotion to the right hypo- 
chondriac region, and the feet, will be beneficial. 

5. The extract of taraxacum often does good in this disease ; but to pro- 
duce effect, it should be administered in larger quantities than are commonly 
given. Its powers are feeble; and less than two drachms every twenty-four 
hours, will not be likely to accomplish anything. 

6. When the disease continues till the succeeding summer, and is accom- 
panied by constipation of the bowels, sulphur-waters, drank for a few weeks, 
are often exceedingly beneficial. But, to prove so, the keen appetite which 
they produce, must not be indulged ; and, by the use of an opiate at bed- 
time, the sulphur should, if possible, be determined to the skin. 

7. In every stage of the disease, the morbid sensibility and irritability of 
the system must be palliated, with gentle narcotics, and antispasmodics ; 
which, as far as practicable, should be so combined with diaphoretics, as to 
act upon the skin. To this end it is advantageous to combine Dover's 
powder, with the evening dose of calomel ; but the constitutional irritation 
often requires the administration of gentle narcotics, and stimulants in the 
day, when a pill of four grains of assafoetida, and a fourth of a grain of 
opium, may be administered, at such intervals as seem necessary. Or, in 
its stead, the following formula may be used : — 

R. — Sulphate of Morphine, gr. ii. 

Sulphuric Ether, - - - - - gij. 

Simple Syrup, - - - - - - ^ii. — Mix. 

A teaspoonful, diluted with cold water, to be taken at discretion. 

As all medicines of this class, soon lose their effects ; and many cases of 
subacute hepatitis continue for a long time ; a change of the narcotico- 
antispasmodic, often becomes necessary; and therefore, I subjoin the fol- 
lowing : — 



174 THE PRINCIPAL DISEASES OF THE 

R. — Tincture of Valerian, ----- ^ii. 

Ammoniated Alcohol, - - - - ^ij. 

Tincture of Opium, gi. — Mix. 

A teaspoonful to be occasionally administered. 

"When we look at the value of the sulphate of quinine, in chronic splenitis, 
we may suppose that, it must be serviceable in chronic hepatitis from autum- 
nal fever, and as it coincides, in action, with the medicines we are now con- 
sidering, it is proper to employ it. Combined with Dover's powder, in the 
proportion of five grains of one to ten of the other, it may be given at night ; 
or it may be administered, now and then, throughout the twenty-four hours, 
according to the following formula : — 

R. — Sulphate of Quinine, ----- ^i. 

" Morphine, - - - - gr. i. 

Aromatic Sulphuric Acid, - gtt. x. 

Sulphuric Ether, - -"'---*' sji. 

Simple Syrup, - - %i. — Mix. 

A teaspoonful to be given as occasion may require. 

8. In many instances, a change of climate becomes indispensable. It 
must always be made from a warmer to a colder latitude ; choosing, at the 
same time, a locality but little infested with autumnal fever. 

9. I do not give a separate consideration to the diarrhoea, which in some 
eases follows on autumnal fever, as it is, generally, symptomatic of liver dis- 
ease, and ceases when its pathological cause is removed. 



SECTION VI. 

DROPSY. 

I. History. — Dropsy is another consequence of autumnal fever. In 
slight cases, the serous infiltration is limited to the lower extremities ; but 
in the graver, extends to the whole subcutaneous cellular tissue, giving uni- 
versal anasarca. Ascites is less common j and, never occurs, I believe, 
without cellular infiltration of the legs and feet. Hydrothorax from this 
cause is exceedingly rare, and hydropericardium, still rarer. 

Dropsy seldom follows on remittent fever, except it terminate in the in- 
termittent form. When intermittents are cured at an early period, dropsy 
seldom appears. Chronic cases are commonly its pathological cause. Some- 
times, when the anasarca commences, the paroxysms of fever cease to recur ; 
and after the lapse of a little time, the effusion ceases, that which had accu- 
mulated is absorbed and the patient is restored. In other cases, both the 
paroxysms and the infiltration, keep on, until the limbs swell to a great size 
and the ascites assumes a formidable character. In such cases, the Fever 
has been peculiarly obstinate, and of long duration; or the constitution has 



INTERIOR VALLEY OF NORTH AMERICA. 175 

been previously broken down by other diseases, or by intemperance. A high 
grade of the lymphatic temperament may, however, lead to the same result. 
Under these sinister circumstances, the disease may prove intractable j and 
hydrothorax, or even hydropericardium, may at last supervene, and prove 
fatal. Dropsy from autumnal fever prevails, as extensively as the Fever 
itself; but whether it occurs more frequently to the North or to the South, 
I am unable to say. 

II. Pathology. — A difference of opinion prevails as to the immediate 
cause of this serous accumulation. 

1. One theory is, that the absorbent system is left in a torpid condition 
by the Fever, in consequence of which the serum, which naturally bedews 
the cellular tissue and the peritoneal sac, becomes accumulated; and the 
practice founded on this assumption is generally successful; a fact which 
supports though it may not establish, the hypothesis. 

2. Another theory, refers it to increased secretion. This has been ap- 
plied to ascites oftener than to anasarca ; the peritoneum having been left, 
it was said, in a state of subacute inflammation. Such a condition of that 
membrane may undoubtedly exist after the Fever, and produce ascites ; 
but we have no evidence of the fact ; or that any degree of inflammatory 
action, prevails in the cellular tissue of the extremities. By experiments 
on the urine, I have found that sometimes it is albuminous ; oftener is 
not. But if that condition should be present, and as Dr. Blackall believes 
indicate inflammation, it does not follow, that it would be in the perito- 
neum, seeing that both the liver and the spleen are more probable seats. 

3. The popular opinion, both in and out of the profession, is, that these 
dropsies are occasioned by diseases of the spleen ; which operate to produce 
effusion, in two modes : a. By the increased secretion from the inflamed 
surface, generating ascites ; b. By the compression of the vena portse, when 
the organ is enlarged, obstructing the return of blood from the abdominal 
viscera, and thus occasioning effusion into the peritoneal cavity ; while by 
compression of the ascending vena cava, it determines a state of venous con- 
gestion in the lower extremities, and a consequent increase of serous effu- 
sion. That a subacute inflammation of the serous covering of the spleen 
may cause increased secretion, is undeniable ; but in many cases, the extent 
of that surface is so entirely disproportionate to the amount of dropsical 
effusion into the cavity of the peritoneum, as greatly to invalidate this hy- 
pothesis ; which, moreover, will not in any degree explain the production of 
anasarca. But may not compression of the vena portae be adopted as the 
pathological cause of ascites ? The answer must be in the negative ; for, 
in the first place, many cases of ascites occur when the spleen is not so en- 
larged as to reach to the linea alba ; and in the second place, it is almost 
impossible that any enlargement, however great, or in whatever direction, 
should exercise a compressing power over that vein. Still less can it be ex- 
ercised upon the hepatic veins. But in reference to anasarca, the opinion is 
held, that the enlarged organ, exerts itself on the ascending cava. In this 



176 THE PRINCIPAL DISEASES OF THE 

case, however, the ascites is left unexplained. Nevertheless, as the two 
forms of dropsy may depend on different pathological causes it is proper 
that splenic enlargement, as a cause of anasarca, should be more carefully 
considered. 

I assume, then, that this enlargement is not a mechanical cause of anasarca, 
and rest the assumption on the following facts : — 

a. It seems nearly impossible, that enlargement of the spleen should 
compress the ascending cava; which not only lies to the right side of the 
vertebrae, but is protected by the aorta, the diameter of which, however, it 
must be admitted, is not equal to that of the cava. And, as the organ 
advances across the abdomen, its convex surface continues in contact with 
the anterior walls, and the stomach and bowels are consequently behind, 
and interposed between, it and the great vein. 

b. Many cases of anasarca follow intermittent fever, when the spleen is 
so little enlarged as not to reach the median line of the abdomen, nor, even 
project beyond the cartilages of the ribs ; and when, of course, its mechani- 
cal action on the vein is an impossibility. 

c. It is a fact of general notoriety, that many persons have their spleens 
enlarged to great dimensions, even for years, without experiencing anasarca. 

d. It is equally true, that when both affections exist, the anasarca may 
be removed, and the enlarged spleen still remain. 

e. We frequently see a considerable degree of oedema of the face and 
other portions of the body, co-existing with the anasarca of the lower ex- 
tremities, and this too when the patient has not just risen from a recumbent 
posture, favoring the diffusion of the serum throughout the cellular system 
generally, but after he has been on his feet throughout ihe day ; showing 
that the effusion had taken place in the upper parts of the body. 

From these facts we may conclude that although enlarged spleen and 
dropsy, often co-exist, after intermittent fever, the former is not a mechanical 
cause of the latter. And, yet, it seems probable, that enlargements of the 
spleen do, but in a different manner, favor the production of dropsy. The 
blood which sojourns in the organ, may, perhaps, undergo changes, which 
contribute to a vitiation of the whole mass. We must, I think, admit such 
changes, though we are unable to show their exact nature. We know that in 
many cases of rupture of the organ, or of cutting into it in post-mortem in- 
spections, the blood which escapes is unusually black and will not spontane- 
ously coagulate. Professor Gross* has cited a great number of authorities, 
for the fact, that in fevers, both the peculiar pulp, and the blood of enlarged 
spleens, may assume a dark, dirty hue, a black-currant-jelly-like appearance, 
or the aspect of tar. Xow, this blood, if the patient should not die, must 
of necessity, sooner or later, make its way through the vena portae, to the 
general circulation ; and thus, if a morbid state of that fluid can be a cause 

* Pathological Anatomy : Article Spleen. 



INTERIOR VALLEY OF NORTH AMERICA. 177 

of dropsy, it may be, that enlargement of the spleen contributes to the pro- 
duction of that disease. 

4. The diseases of the liver, studied in the last section, have been regarded 
as the cause of dropsy. Let us look at the facts in support of this 
opinion : — 

a. Diseases of the liver, from intemperance, produce permanent jaundice, 
and, finally, all the different forms of dropsy ; and why may not hepatic dis- 
eases, from autumnal fever, originate the same effusion ? 

b. But it may be said, that remittent fever disorders the liver more than 
intermittent, while dropsy oftener follows the latter than the former. This, 
however, may be for the reason, that intermittents so often follow remittents. 
The mischief to the organ, may have been done in the early stage of the 
fever : its consequences may show themselves after the fever has ceased, or 
changed to an intermittent. Original intermittents, however, do themselves 
produce lesions of that organ, of which every physician, in the Valley, must 
have seen examples. 

c. We can perceive how organic disorders of the liver may produce dropsy. 
First. An obstructed circulation through the organ, necessarily leads to a 
state of venous congestion, in all the portal viscera, which may be the proxi- 
mate cause of increased serous secretion into the peritoneal sac, and the 
production of ascites. Second. When tumefied, the organ from lying near to 
and on the same side of the vertebral column with the vena cava, may com- 
press it, and thus generate anasarca. 

d. Besides the function of transmitting the blood from the other abdomi- 
nal organs, the liver is charged with separating from it the elements of the 
bile, which, failing adequately to do, they accumulate in that fluid. It ap- 
pears, moreover, that in autumnal fever, there is an extraordinary develop- 
ment of biliary elements ; and that a copious secretion and excretion of bile 
is, in general, a condition of perfect recovery. Here, then, we have an abun- 
dant source of impurity of the blood ; and to this pathological state, we may, 
perhaps, in part, ascribe the hydropic effusion. 

5. It is well known, that in protracted intermittent fever, the sweats, 
which follow the occasional paroxysms, are generally offensive. Even while 
I am writing this article, a student, laboring under a relapsing intermittent, 
with subacute inflammation of the spleen, but without liver disease or dropsy, 
assures me that the perspiration which follows every return of his chill and 
fever is sour and disgusting in its odor ; a sufficient evidence of a patholo- 
gical state of the blood. 

6. The state of the urinary secretion, in autumnal fever, has not been well 
studied. We know, however, that the quantity of urine is often deficient ; 
and that, in chronic cases, it frequently throws down sediments ; another 
evidence that the blood is unhealthy. 

7. To these sources of impurity we may, perhaps, add one more — the 

VOL. II. 12 



178 THE PRINCIPAL DISEASES OF THE 

constitutional morbid action of the solids. Whatever difficulty may now 
exist, or may forever exist, in comprehending the reciprocal actions and re- 
actions of the blood and the containing solid tissues, no accurate observer 
can fail to notice many proofs of their reality. The blood and the solids are, 
in fact, so united anatomically and physiologically — placed in such relation 
to each other — that, a priori, it seems quite impossible for one to be in a 
morbid condition, without affecting the other ; and hence, in the course of 
a protracted and relapsing intermittent fever, the blood may become impover- 
ished in its red corpuscles or fibrine, or be otherwise deteriorated. 

To the morbid condition of that fluid, generated in so many different 
ways, we should, no doubt, ascribe the leucophlegmatic, wan, leaden, or 
sallow appearance of those who have long had ague and fever ; and we may, 
perhaps, refer to the same pathological cause, the copious hemorrhages from 
the stomach and bowels; which, as we have already seen, sometimes follow 
that disease, and which are commonly, but not intelligibly, ascribed to en- 
larged spleen. . Of the tendency to hemorrhage, created by a deteriorated 
state of the blood, we have instructive examples in scurvy. 

Let us now proceed to inquire whether we can deduce the dropsy con- 
sequent on autumnal fever, in whole or in part, from this sanguineous 
vitiation. 

8. In proceeding to do this, we must exclude from the inquiry, First. 
The cases of ascites, which arise from subacute inflammation of the perito- 
neum. Second. Those which result from obstructed transmission of blood, 
through the hepatic ramifications of the vena portse; and Third. Those ana- 
sarcas, if any, which are caused by the pressure of an enlarged liver on the 
ascending vena cava. After excluding all the cases which result from these 
pathological causes, I suppose a much larger number remain unaccounted 
for, and to them we must now give attention. 

The pathological data, which lie before us, are the following : First. A 
relaxed and inactive state of the solids generally ; Second. An impaired 
activity of the organs of excretion, especially of the skin, liver, and kidneys. 
Third. A deteriorated state of the blood. 

Now, it is a physiological law, that if matters foreign to the constitution 
of the blood, find their way into it, by absorption, either external or inter- 
stitial ; or are developed in it by disorder of the solids ; or retained in it by 
defect of excernent action, they must either be decomposed and become a 
part of that fluid ; or be eliminated through some of the emunctories of the 
system, or into its cavities. In the case of poisons injected into the blood- 
vessels, some take one direction, others another. Iodine and nitrate of 
potash seek the kidneys — emetine and phosphorus the lungs — tartar emetic 
the mucous membrane of the bowels. But in the case of dead organic 
matter, such as we suppose to pollute the blood in the pathological condition 
we are now studying, there may not be an eclectic tendency, for the reason 
that it has lately belonged, as it were, to the whole system ; and if it should 



INTERIOR VALLEY OF NORTH AMERICA. 179 

direct itself upon the great organs of excretion, it might not be able to rouse 
them from their torpor. It is left, then, to irritate the serous and areolar 
membranes, and increase their exosmosis : a passive function, for which 
they are at the time so much the better fitted, as they are the more relaxed 
or reduced in texture and vital force by the previous fever. In this way 
appear to be generated those dropsical accumulations, which we are now 
studying ; to the more rapid increase of which a defective absorption may 
be an auxiliary cause. 

III. Treatment. — Let us test these hypotheses by studying the thera- 
peutics which they demand, and comparing them with what experience has 
shown to be successful. First. Should a subacute inflammation of any ab- 
dominal organ or tissue, still remain, it should be subdued. Second. The 
great excretory functions must be re-excited ; and, some one at least, brought, 
for a while, into greater activity than in health. Third. Absorption must 
be promoted. Fourth. The blood must be renovated, and the tone of the 
solids restored. 

Such are the indications to be fulfilled, and they demand the very means 
which are known to be most efficacious ; the study of which, in detail, must 
now receive attention. 

1. When subacute peritonitis, hepatitis, or splenitis, or any complication 
of them, is known to exist, bloodletting, general and topical, must be the 
first remedy ; under the free resort to which an immediate improvement' 
often takes place; for secretion will be diminished and absorption pro- 
moted. As to the other antiphlogistic measures, they are so much the same 
with those required to fulfil the next indication, that they need not be here 
enumerated. 

2. To re-excite the excretory functions, the means specifically adapted 
to each must be employed, but not at the same time. In fixing on any 
one with which to begin, the physician must exercise his sagacity. If the 
bowels have been torpid and costive, he may select them -, if the liver, it ; if 
the kidneys, them ; he may even choose the skin and be successful. In 
administering the agents, respectively, appropriate to these great secretory 
outlets, if there be some degree of phlogistic diathesis, from visceral inflam- 
mation, he must choose the refrigerant and sedative. On the other hand, 
if the vital forces be greatly reduced, he should select the most exciting, 
and often administer stimuli at the same time, or the evacuants will not 
promote excretion. But a measure, preliminary to all others, may be the 
administration of an emetic, which tends to arouse the organs, generally, 
into increased activity, and gives greater efficacy to all that is subsequently 
done. 

If the liver and bowels be fixed upon, as the first to which our remedies 
are to be directed, five grains of calomel or blue mass, with an equal quan- 
tity of Dover's powder, should be administered at bedtime ; and, the follow- 
ing day, two scruples or a drachm of a powder, composed of equal parts of 



180 THE PRINCIPAL DISEASES OP THE 

jalap, nitre, and cream of tartar; to be aided in its operation, if necessary, 
with an infusion of senna and Epsom salt. On the following night, the 
calomel and Dover's powder should be repeated, and, on the next day, the 
hydragogue. This course may be pursued for three or four days, according 
as the strength of the patient seems, or does not seem, to admit of it. But, 
as a substitute for the cathartics mentioned, a sixth of a grain of elaterium 
and a scruple of cream of tartar, may be administered every two hours, 
beginning early in the morning, and continuing it until purging is produced. 
If, by these means, copious watery discharges, colored with bile, are effected, 
a rapid absorption of the effused fluid, and a consequent reduction of the 
swelling, will take place. Should the quantity of Dover's powder, men- 
tioned, be found too small to produce tranquillity and sleep at night, it 
must be increased j and should the purging reproduce the ague, five or ten 
grains of sulphate of quinine, must be added to the opiate. 

If this course should not have been adopted, or have been prosecuted 
without effect, the physician must determine his efforts upon the kidneys. 
He may still, however, act upon the liver with calomel or the blue mass, in 
conjunction with diuretics. A composition which, perhaps, exerts more 
power in these cases than any other, is two grains of one of the mercurials 
just mentioned, two of squill, and eight or ten of nitre, intimately incorpo- 
rated, and administered, in the form of a bolus, every two hours, until the 
secretion of urine is augmented ; and, then, every four hours, omitting the 
mercurial, if signs of approaching salivation should appear. As it will not 
affect the kidneys, should it act on the bowels, opium may be necessary. 
After this course has been continued for a few days, a copious flow of urine 
will, in general, take place ; and, at the same time, a diminution of the 
swelling will denote the progress of absorption. Other sedative diuretics 
are employed in the Valley ; of which I will only mention, as the best, an 
infusion of digitalis with the spirit of nitrous ether, taken in a solution of 
cream of tartar; and the hydriodate of potash, in ten or fifteen grain doses, 
three or four times a day. 

Of stimulating diuretics, the oil of turpentine, in such doses as will not 
purge, often does good ; and in cases of great torpidity, the tincture of can- 
tharides may be given until strangury is excited, after which one of the 
compounds mentioned above, will keep up the discharge. Grin and water, 
or, even whiskey and water, are well adapted to cases of this kind. An in- 
fusion of green tea, taken cold, often produces a decided effect. My pre- 
ceptor, Dr. G-oforth, was exceedingly partial, in these cases, to the following 
popular and domestic formula : — 

R. — Parsley-Root, - 
Horse-Radish, - 

Black Mustard Seed, - - - - } each § iv > bruised ' 
Juniper Berries, - 

Squill, 

Rust of Iron, - 



:i 



" 1 " &s. 



INTERIOR VALLEY OF NORTH AMERICA. 181 

Mix and infuse in a gallon of hard cider for three days, in a covered 
vessel, and then, immediately after strong agitation, pass the liquid through 
a thin strainer, and bottle. The dose is from two to four ounces, four or six 
times a day. That the undissolved carbonate of iron, may be taken, the 
bottle should be agitated before pouring out the dose. I have repeatedly 
prescribed this compound with the happiest effects ; and it is generally ac- 
ceptable to the patient, because he regards the ingredients as simples. 

In general, the diuretic treatment should be continued longer than the 
purgative ; but there are limits beyond which it should not be carried, and 
the physician ought, at length, to turn his attention to another great func- 
tion, that of the skin. This may, indeed, have been already done to some 
extent ; for when Dover's powder was administered at night, and the purg- 
ing was suspended, some influence was necessarily exerted on the external 
surface. The restoration of its functions, should now, however, become the 
main object, and, therefore, neither cathartics nor diuretics, should be ad- 
ministered. In the prosecution of the diaphoretic plan, warm bathing, local 
or general, with frictions and shampooings, should be employed ; and ten 
grains of Dover's powder, with five of sulphate of quinine, given, once or 
twice every night, with hot infusions of balm, sage, sassafras, thoroughwort, 
or serpentaria. When, however, the powers of the systeurare greatly reduced, 
hot gin, or whiskey toddy, should be preferred; or one of those stimulants 
should be added to one of the infusions just mentioned. In the daytime, 
the patient should be kept in bed, or at least within doors, otherwise the 
perspiration wiil be checked. Many years ago, Dr. Allison, who had been 
Surgeon-General of Wayne's Army, told me that he had cured a female 
patient of anasarca, following on intermittent fever, by making her drink hot 
gin toddy, and dance daily to fatigue, in a warm room. 

The excitation of the absorbents, has been stated as one of the objects to 
be accomplished. It may, indeed, be said to be the great end in view. But, 
it will be perceived, that very little remains to be said under this head ; for 
all that has been advised, has contributed to fulfil this indication. Moreover, 
of medicines that act specifically on the absorbent system, we know but 
little. Nevertheless, it seems probable, that digitalis exerts an effect of 
that kind j as we seldom observe diuresis under its administration, except 
when there are dropsical effusions ; which being absorbed, irritate the kidneys 
into increased secretion. There is litttle doubt, moreover, that iodine exerts 
an influence on the absorbent system \ and hence, perhaps, in part, the effi- 
cacy of the hydriodate of potash, in the diseases under consideration. But 
there are means of a different kind, for promoting absorption — these are 
compression and exercise. As a general rule bandages will accomplish but 
little, till the absorption has commenced ; when they should never be omitted, 
from both the limbs and abdomen, if the disease exist in both. Of the 
power of exercise over the absorbent system, there can be no doubt. When 
the abdominal distension is great, it cannot be taken, because the diaphragm 



182 THE PRINCIPAL DISEASES OF THE 

cannot descend ) and if there be enlarged spleen, the difficulty will be much 
increased. But in the treatment of anasarca, the value of active, or sus- 
tained locomotion, will be decisive. Its effects are not limited to the action 
of the muscles upon the veins and lymphatics ) but found, likewise, in the 
increased exhalation from the lungs from deeper and more frequent inspira- 
tions, which tend at once, to the elimination of the absorbed fluid, as if 
from the skin or kidneys ; and to an improved condition of the impoverished 
blood. And this brings us to our last indication — the restoration of the flesh 
and strength of the patient. 

Tonics, scarcely ever to be omitted, after the absorption of the serum has 
been effected, may, in many cases, be advantageously administered before. 
For example, when there is still a strong tendency to the recurrence of the 
febrile paroxysm, under slight exposure, or at quartan, or heptan periods, 
the bark alone, or combined with cream of tartar, will contribute to dimi- 
nish effusion and promote absorption, as well as arrest the recurrence of the 
Fever. And when the effusion has suddenly become very great, with a 
feeble pulse, and cool or cold, bloodless, and semi-transparent skin, that 
medicine, and the proto-carbonate, proto-tartrate, or proto-sulphate of iron, 
are powerful means of arousing the system into increased absorption and 
secretion ; while they contribute to augment the solid materials of the blood, 
and thus diminish the tendency to the effusion of serum into the cavities. 
Of the whole, the proto-carbonate has, perhaps, been most frequently em- 
ployed ; and there is much testimony in its favor. The iodide of iron, and 
the hydrocyanate of quinine are, also, well adapted to such cases. 

The absorption of the serum having been effected, some of the medicines, 
just named, alternated with vegetable bitters, must be continued for a con- 
siderable length of time ; great care being taken to keep the secretions in a 
healthy condition, by such means as are least debilitating. If they should 
fail, the effusions will recommence. At the same time, compression, frictions, 
and percussions, should be applied to the limbs ; and kneading with the fists 
to the abdomen, should there be nothing in the state of the liver or spleen 
to forbid them. The diet of the patient should be mixed and nutritious, 
but not in excess ; and he should take as much exercise in the open air as 
possible ', having the surface of his body well protected. 



SECTION VII. 

PERIODICAL NEURALGIA. 

I. Prevalence, Seasons, and Subjects. — Relying upon the informa- 
tion received of others, in connexion with my own experience, I may say, 
that neuralgia is decidedly the most frequent of all the consequences of 
autumnal fever. It prevails from North to South — everywhere, indeed, that 
our periodical fevers occur; but most, where intermittents are most prevalent 



INTERIOR VALLEY OF NORTH AMERICA. 183 

in comparison with remittents. Dr. Flournoy, of Lexington, Missouri, is 
the only physician who has told me that he had seen it precede the fevers of 
autumn. Its subjects, then, were probably those who had experienced 
attacks of the fever the year before. In general, it follows the annual epi- 
demic; and, therefore, occurs chiefly in winter, and in spring, when vernal 
intermittents prevail. Occasionally, in certain localities, the number of 
winter cases is so great as to constitute it a kind of epidemic. From June 
to December, it is comparatively rare. It affects adults more than children, 
and men more than women ; at least, this is what I have observed in my own 
practice. In some cases it becomes so established as to return with great 
frequency for years. Such, for a long time, was the condition of the late 
President Harrison, who resided in a locality infested with intermittent 
fever. Many years ago, I knew a Philadelphia merchant who travelled much 
in the West, and was obliged always to carry with him a quantity of the 
bark — the only medicine which afforded him relief. 

II. Seats and Symptoms. — The true type of this painful affection, and 
by far, the most common, is known under the popular name of " sun-pain f 
by the profession called periodical hemicrania. Its common seat is the right 
or left extremity of the forehead ; but it often spreads over the entire orbit 
of the eye. Occasionally it runs back to the occiput, limiting itself to one 
side ) but now and then it attacks the whole head j raging, however, with 
greatest intensity in the frontal region, and generally more on one side than 
the other. In some cases the skin of the forehead shows a considerable degree 
of hyperemia; but I never saw evidences of inflammation. When it ex- 
tends to the orbit, the eye becomes red, there is a copious secretion of tears, 
and considerable intolerance of light. It commonly shows a distinct quoti- 
dian, intermittent type ; but, in some cases, is tertian ; and now and then 
only remittent. I cannot say, that the paroxysms are never ushered in with 
a distinct chill ; but do not recollect its occurrence in my own practice, nor 
has it been mentioned to me by others. Although the paroxysm may recur 
at any time in the twenty-four hours, its legitimate period is the latter part 
of the night or early in the morning; which, with its gradual increase during 
the forenoon, and its abatement or entire cessation toward night, has pro- 
cured for it the name of " sun-pain/' As it ceases, the redness of the eye, 
when that organ is involved, diminishes or disappears, and the tolerance of 
light returns. 

As to constitutional symptoms, the liver, stomach, and bowels, are much 
less disturbed than in relapses of intermittent fever. The pulse is apt to 
be accelerated during the paroxysm, and, occasionally, there is some develop- 
ment of heat in the skin ; but, in many cases, scarcely a single symptom of 
fever is present. 

I must now enumerate other parts of the body in which this affection has 
been observed, by those with whom I have conversed j having also witnessed 
several of them myself. 



184 THE PRINCIPAL DISEASES OF THE 

In the North, Dr. Conant has seen it in various parts of the body ; Dr. 
White saw one case in which it occurred about the middle of the humerus ; 
Drs. Baker and Kitterage have seen it in the extremities ; Dr. Wallace, in 
the teeth and side of the chest ; Dr. Dresbach, in the sacrum, coccyx, and 
lower extremities. In one case it attacked the spermatic cord and testicles 
and the paroxysm alternated with others in the head, feet, and stomach. In 
the West, Dr. Price has frequently seen it attack the stomach — in one in- 
stance, that organ and the diaphragm, the paroxysms coming on regularly 
at midnight; Dr. M'Cullough has known it assail the os occipitis, the right 
side of the chest, and the wrist. To the South, Dr. Christian has had two 
cases in which it occurred in the splenic, and four in the uterine region ; Dr. 
Kittral has twice seen it in the ear ; Dr. Walkly had a case in which, under 
the influence of electro-magnetism, it shifted to a tooth, then to the external 
angle of the eye, then to the temple of the opposite side, and then to the 
arm, when it ceased ; Dr. Barnett has seen several cases in which it fell upon 
the uterus, and, also, upon the tongue; Dr. M'Murtery has seen it affect 
the testicle and the liver; Dr. H. C. Lewis saw a case in which, after a white 
swelling of the knee-joint, it attacked the gastrocnemii muscles of the same 
limb, and returned the next autumn in the same part. Finally, it is a 
familiar fact, that the membranes of the jaws, and even the teeth, are often 
attacked. Thus, I have seen the pain of decayed teeth return at regular 
diurnal periods. 

In addition to these citations, which show that various parts of the body 
are affected, I may add, that many cases of what, from their history, are 
called chronic rheumatism, have such diurnal or nocturnal exacerbations as 
should, perhaps, entitle them to a place in the catalogue of neuralgias. 

Although the affections we are now studying very commonly follow at- 
tacks of autumnal fever, many cases do not. They depend, however, on the 
same cause, but occur without the intervention of the Fever. This is proven 
by their prevailing in the same places, having the same symptoms, and being 
cured or relieved by the same treatment. In general, the cases which have 
not been preceded by fever, are of the mildest grade. The disease we are 
now considering, doubtless attacks many parts of the body, not highly en- 
dowed with sensibility, and disturbs their functions, without giving the acute 
pain of neuralgia. Such cases may be detected by their periodicity, and 
the absence of the signs of inflammation. Professor Gross, whose popu- 
larity as a physician equals his fame as a surgeon, has, as he informs me, 
met with such cases, from the country around Louisville ; and they have also 
occurred in my own practice. 

III. Pathology. — Periodical neuralgia, is a pain or aching of the white 
fibrous tissues; but sometimes of the red; and, perhaps, also of others. 
The nervous irritation is not generally, or necessarily, of that kind which 
invites blood into the part, though such a fluxion may be produced. A true 
inflammatory action is, however, not set up; for the irritation ceases, and 



INTERIOR VALLEY OF NORTH AMERICA. 185 

with it the hyperemia, before the inflammation can be established. When 
it attacks the fibrous membranes of the cranium, it is sometimes mistaken 
for arachnitis ; and I have seen the paroxysms become progressively worse 
under an antiphlogistic treatment. Why it is oftener seated in the extremi- 
ties of the fifth pair of nerves, than any others, I cannot tell ; but we have 
long known, that ordinary tic douloureux has its chosen seat in the same 
nerves. The reason that a part which is affected with periodical neuralgia, 
does not suffer organic changes, is to be found I suppose, in the absence of 
inflammation, the immediate cause of most lesions of structure. This nega- 
tive character, taken in connexion with its periodicity, places the disease 
among the neuroses, and reveals to us the true character of intermittent 
fever, as far as the primary impression of the remote cause is concerned. 
It, also, teaches us why that fever cannot, in general, be arrested by means 
which only lower the excitement of the system; and why it readily yields 
to opium and quinine, when the system is brought, by depletion, into a state 
favorable to their action. But the disease, in both its febrile and its neu- 
ralgic stages is of a peculiar kind, and therefore, not every agent which acts 
powerfully on the nervous system, will arrest it. 

IV. Treatment. — I know of no disease in the treatment of which our 
physicians are so unanimous, as of that now before us. From North to 
South it is essentially the same. Everywhere the sulphate of quinine is 
the popular remedy j and by nearly all it has been found infallible. But 
this infallibility, in many cases, is limited to an arrest of the paroxysms ; 
which after a while may recur. In fact, this painful affection obeys the 
same laws as protracted and relapsing intermittent fever. By some physi- 
cians, the quinine is administered without any preparation of the system ; 
while others always subject their patients to the operation of emetic and 
cathartic medicines. There are cases which do not, and others which do, 
require that preparatory treatment. As a general rule, the longer and 
oftener the disease has returned, the less is the necessity for those evacuants ) 
and of the two, emetics are more beneficial than cathartics. Sometimes, 
when the quinine has failed before, it has succeeded after the operation of 
an active emetic. When the attack is violent, and distinctly marked with 
diurnal, or nocturnal paroxysms, opium is a valuable adjuvant to the quinine. 
Thus, a grain of that medicine, or ten grains of Dover's powder with ten 
of quinine, may be administered at bedtime ; and another dose of the same 
kind before day in anticipation of the paroxysm ) which it will generally 
avert, provided the patient continue in bed during the forenoon. But in 
some cases the proportion of opium may be doubled. The next night half 
the quantity of these medicines will be sufficient. In obstinate cases of long 
standing, a method not so prompt will be preferable. Thus, the bark in 
substance may be administered in drachm doses, three or four times a day. 
Or a compound of quinine, opium, and arsenious acid, as for relapsing in- 
termittents, may be substituted for it. Dr. _ Vivian, of Missouri, assured 



186 

me that he had found the carbonas-ferri of much service in some cases of 
this kind. A variety of local applications have been made. In my own 
practice they have done but little good. Yet a blister to the nape of the 
neck has, occasionally, given immediate relief, the pain being seated in the 
face or head. Of other applications, over the affected part, Dr. Barnett, 
of Mississippi, and Dr. W. A. Davison, of Missouri, informed me, that 
they had seen veratria afford relief; that Dr. Talbot, of the latter State, 
has employed a saturated alcoholic tincture of stramonium seeds with ad- 
vantage. 



The article Autumnal Fever is now brought to a close. It has ex- 
tended through many pages ) but a smaller number would not have sufficed, 
to present even an outline of its etiological and therapeutic history through 
so wide a geographical range as that of the southern half of our Interior 
Valley, in almost every part of which it is an annual endemio-epidemic. 
Of all our diseases, it is the one which has the most intimate relations with 
soil and climate — that, in which peculiarities, resulting from topographical 
and atmospheric influences, are most likely to appear. Hence it was 
chosen, to stand next to the Book of G-eneral Etiology as illustrating 
better than any other disease, the importance of the facts which make up 
that Book. It is, moreover, the great cause of mortality, or infirmity of 
constitution, especially in the southern portions of the Valley, and there- 
fore, entitled to severe and patient attention. What I have collected and 
presented has required more labor than many of our brethren might sup- 
pose j and yet, they will not, perhaps, realize as fully as I do myself, how 
much must be added — how many errors corrected — before the pages through 
which they have travelled can be entitled to universal acceptance. Mean- 
while, if what has been written should stir up a single young physician 
to a more diligent observation of the Fever, or save the life one individual, 
who might otherwise have become its victim, my labor will not have been 
in vain. 



PART SECOND. 

YELLOW FEVER. 



CHAPTER I. 



SECTION I. 

NOMENCLATURE — DEFINITION — SOURCES OF INFORMATION. 

I. Nomenclature. — The term yellow fever is at once euphonic in sound 
and expressive of the most common characteristic appearance of a patient 
laboring under the disease now before us; the synonyms, vonrito and vomito 
prieto, or black vomit, are not likely to supplant that name, wherever the 
English language is spoken. There are physicians, however, who prefer 
the epithets bilious yellow fever, and malignant bilious fever ; having con- 
vinced themselves that this fever is but a modification of autumnal fever. 
As the word bilious has long been appropriated to the last, I shall not em- 
ploy it in this article ; and to show that the two fevers vary beyond the 
limits of mere modification, it is proper, at the outset, to present a con- 
densed statement of the diagnostic symptoms of yellow fever. 

II. Definition. — A summer and autumnal epidemic fever, of one chill, 
followed by a single hot stage, running through forty-eight or seventy-two 
hours; accompanied with pain in the head, back and legs; jactitation; red 
eyes ; gastric irritability, and biliary derangements, terminating sooner or 
later in jaundice; the fever succeeded by a stage of apyrexia and com- 
parative tranquillity, suppression of urine, hemorrhage from various parts 
of the body, black vomit, and death. When the patient recovers, the three 
latter symptoms do not commonly appear, and if he remain in the place 
where the fever was contracted, he generally enjoys an immunity from 
subsequent attacks. 

In all the modifications, most of these symptoms are present ; and in the 
absence of a majority of them, the case would not be acknowledged as yellow 
fever. 

III. Sources of Information. — I have never seen a case of yellow fever ; 
but am not precisely in the condition of a historian, who might have only 



188 THE PRINCIPAL DISEASES OF THE 

printed works from which to compile. I have visited and studied the topo- 
graphy, hydrography, and climate of a number of the most infested locali- 
ties; and what is of equal or greater advantage, enjoyed the opportunity of 
conversation with a great number of physicians, who had become familiar 
with the disease in all its aspects. A large part of the facts about to be 
presented was thus obtained ; while the remainder have been drawn from 
publications by physicians resident in the region embraced in the plan of 
this work. 

Thus it is our own yellow fever, that of the Gulf of Mexico, and tributary 
rivers, that will be here described ; and if the description should not be true 
of the disease as found in all countries, it will be because it is true of that 
which prevails in our own. 

SECTION II. 

GEOGRAPHY AND CHRONOLOGY. 

I. Geography. — The southern limits of yellow fever, like those of autum- 
nal fever, lie within the tropics. At Vera Cruz and Havana it has long pre- 
vailed as an endemio-epidemic. From these cities around to New Orleans 
it^ has invaded every town, situated on the islands or estuaries of the Gulf 
of Mexico. Its prevalence has been chiefly below the thirtieth parallel ; 
but it has once visited Memphis* on the thirty -fifth parallel, and prevailed 
there as an epidemic. If cases have now and then occurred in places fur- 
ther north, as Cairo, Paducah, and St. Louis, the disease had been contracted 
in some town lower down the river. Its favorite haunts are the Gulf coasts, 
and the delta and bluffs of the Mississippi. 

Yellow fever is essentially a disease of towns and cities. The inhabitants 
of the country even within a few miles of a town where the disease is epi- 
demic generally escape it; unless they venture within its sphere of pre- 
valence. An epidemic invasion of the country is unknown; although it 
has happened that persons living in the vicinity of a town have sometimes 
suffered. 

The fever is not confined to the land, but often breaks out among the 
crews of ships navigating the Gulf of Mexico, long after they have visited 
any port at which it was prevailing. 

Nearly all the places in which yellow fever has occurred, were but little 
elevated above the level of the Gulf. At Xalapa, in the latitude of Vera Cruz, 
it is unknown, the altitude being 4330 feet. The mean annual heat of that 
city is the same with that of Natchez, 67° Fahr. ; but while the summer 
temperature of the latter is 80-96°, that of the former is but 69-32°. At 
what point before reaching the altitude of Xalapa, the fever ceases to pre- 
vail, I am not informed. Along the Mississippi, one of the most elevated 

* See Vol. I. p. 133. 



INTERIOR VALLEY OF NORTH AMERICA. 189 

spots at which it has appeared, is the summit of the knobs on which the 
upper parts of Vicksburg are built. The elevation, I do not know, but 
suppose it to be about 350 feet. That o£ Memphis, however, is estimated 
at 400 feet, and the disease as we have seen has occurred there once. This 
is the greatest elevation it has reached in the Mississippi Valley. 

Yellow fever not only affects lowlands, but also water-side localities. 
With two or three exceptions it has prevailed in no place not visited by 
ships or steamboats. The exceptions are Opelousas, in Louisiana, and 
Washington and Woodville, in Mississippi. The last is about twelve miles 
from the Mississippi River, which is the greatest distance from a navigable 
water at which it has as yet appeared. 

It deserves to be recorded, that while various places on the bayous or 
main trunk of the Mississippi, have been repeatedly invaded, the towns on 
Alabama River, lying in the same latitude and elevation, have escaped. 

II. Chronology. — There is some reason to believe that yellow fever has 
been a disease of the shores of the Gulf of Mexico, from Cuba round to 
Vera Cruz, since the first settlements were made upon them by Europeans ; 
but as it is a civic rather than a rural disease, it was probably less prevalent 
in the infancy of the cities of the Gulf than in their more advanced and 
populous condition. I have not the materials for a notice of its early history 
in the cities just named. On the shores of the northern segment of the 
Gulf, the first notice of the disease was at Biloxi Bay, in 1702, and Mobile 
in 1705.* The next was in Pensacola and Mobile in 1765, when it prevailed 
as an epidemic. f As Capt. Romans believed it to be imported from Cuba, we 
discover that the disease prevailed on that island at that time. In fact, we 
learn from Lind, p. 168, that in other parts of the West Indies very violent 
fevers raged in certain localities, in the years 1765-6. J I have not met with 
any other printed or traditional account of the disease in that region, for the 
next thirty years, that is, down to the time of the first authentic notice of 
its occurrence in New Orleans, in 1796. § Throughout that period, the prin- 
cipal villages were St. Marks, Pensacola, Mobile, Pascagoula, Biloxi, Bay 
of St. Louis, the Balize, New Orleans, Baton Rouge, and a few other settle- 
ments in and above the delta of the Mississippi. There was but little emi- 
gration to them ; they had, with the exception of New Orleans, scarcely any 
commerce, and were composed chiefly of French and Spanish Creoles, whose 
connexions were with the mother countries, where the records of yellow 
fever invasions are doubtless deposited, if any exist. Since the date just 
mentioned, that is, for more than half a century, the invasions of the disease 
have been noted; but of the majority, no histories have been preserved. 
They have been frequent, especially in New Orleans ; and to save the reader 

* Dr. Lewis, N. O. Medical Journal, Vol. 1, No. 4. 

t A concise History of East and West Florida. By Captain Bernard Romans. New York, 1776. 
t An Essay on the Diseases incidental to Europeans in Hot Climates, by James Lind, M.D., Philadel- 
phia, 1811. 
I Dr. Carpenter. 



190 THE PRINCIPAL DISEASES OF THE 

from the unwelcome labor of travelling through a narrative, I have thrown 
the whole into a chronological table. It is not practicable to connect the 
authorities with this table ; but after stating that I have collected and col- 
lated them with much care, I may mention the classes to which they may 
be referred. 1st. Printed accounts, which are in the hands of the profession. 
2d. An examination of the registers of the great Charity Hospital, which 
begin, in an intelligible manner, with the year 1818. 3d. Conversation or 
correspondence with living physicians of all the towns and cities, except a 
few of the smaller, where it has appeared for a single time only. 

The initial letters E. and S., affixed to the places named in the table, 
signify Epidemic and Sporadic j in reference to which I should observe, that 
as they do not represent fixed or definite degrees of prevalence, the informa- 
tion conveyed by them must be regarded as vague, and of the most general 
kind. Thus the word sporadic will indicate any degree of prevalence, from 
a few cases up to such a number, as might justify the epithet epidemic, or 
even render it the more proper of the two. In treating of the disease as it 
has occurred in the different towns, greater precision will be attainable. 

Chronology of Yellow Fever in the Valley of the Mississippi River and its 

Borders. 

Endemic ; Havana, Yera Cruz. 

1702. Biloxi; Dr. Lewis, N. 0. Med. Journal, No. 4. 
1705. Mobile, E. ; Dr. Lewis, N. 0. Med. Journal, No. 4. 
1765. Mobile, E. ; Bernard Romans; Pensacola, Lind., E. 
1791. Prevailed; Mr. Relf. N.B. See Histoire de la Louisiane, par 
Gayani, Secretary of State, 1704-06. 
1796. New Orleans, E. 

1799. New Orleans, E. 

1800. New Orleans, E. ; Barton Am. Journal. 

1801. New Orleans. Prevailed more or less. Mr. Mansell White had 
it. Knew of several deaths. 

1804. New Orleans, E. 

1811. New Orleans, E.; Pensacola, E. ; St. Francisville, S. 

1812. New Orleans, E. 

1817. New Orleans, E. ; Baton Rouge, E. ; Natchez, E.; WhitzelFs 
Landing, twenty miles below Natchez. 

1818. New Orleans, E. 

1819. New Orleans, E. ; Mobile, E. ; Baton Kouge, E.; Natchez, E. 

1820. New Orleans, E. ; Bay of St. Louis, E. 

1821. None. Mobile, S. 

1822. New Orleans, E.; Mobile, S. ; Pensacola, E. ; Blakely E. ; Baton 
Rouge, E. 

1823. Two cases, Charity Hospital, S. ; Natchez, E.; Coonsville, E. Dr. 
Thomas says positively no Yellow Fever in New Orleans. 



INTERIOR VALLEY OF NORTH AMERICA. 191 

1824. New Orleans, E.; Mobile, S. ; Key West, E. 

1825. New Orleans, E. ; Mobile, E. ; Natchez, E. ; Washington, E. 

1826. New Orleans, S. ; ApalachicolaBay. 

1827. New Orleans, E. ; Mobile, S. ; Pensacola, E. ; Baton Rouge, S.j 
Natchez, S. ; Bayou Sara, S. ; Vicksburg, S. 

1828. New Orleans, E. ; Mobile, S. ; Memphis, E. 

1829. New Orleans, E. ; Baton Rouge, E. ; Plaquemines, E.; Natchez, 
S. ; Bayou Sara and Francisville, E. ; Bay of St. Louis, Army, E. j Mobile, 
E. J Key West. 

1830. New Orleans, E. 

1831. Three cases Charity Hospital, S. 

1832. New Orleans, E. j Mingled with cholera. Reported as cholera in 
Charity Hospital. Many testify to its prevalence. 

1833. New Orleans, E. j Plaquemines, S. 

1834. New Orleans, E. ; Pensacola, E. 

1835. New Orleans, E. 

1836. Seven cases, Charity Hospital, S. 

1837. New Orleans, E. ; Mobile, E. j Natchez, E. ; Plaquemines, S. ; 
Vicksburg, S. j Opelousas, S. 

1838. New Orleans, S. ; Mobile, S.; 

1839. New Orleans, E. ; Mobile, E. ; Pensacola, E. ; Bay of St. Louis, S. ; 
Pascagoula, S. ; St. Joseph's, S.; Bay of Biloxi, S.; Tampa Bay, S. ; Frank- 
lin, E. ; New Iberia, E. ; St. Martinsville, S. ; Opelousas, E. j Thibadeaux, 
S. j Donaldsonville, S. ; Plaquemines, E. ; Baton Rouge, E. ; Bayou Sara, 
E. ; Waterloo, E.; Fort Adams, E. ; Port Hudson, E. ; Natchez, E. ; 
Vicksburg, E.; Alexandria, E.; Nachitoches, E.; G-alveston, E.; Houston? 

1840. Two cases, Charity Hospital, S. 

1841. New Orleans, E.; Mobile, S.; Pensacola, E. ; Port Hudson, E. ; 
Vicksburg, E. 

1842. New Orleans, E. ; Mobile, S.; Opelousas, E. 

18-13. New Orleans, E; Mobile, E. ; Donaldsonville, S. j Baton Rouge, 
S. ; Vicksburg, E. ; St. Francisville, E. j Rodney, E. ; Port Hudson, S. 

1844. New Orleans, S. j Woodville, E. ; Mobile, S. 

1845. New Orleans : one case in the Charity Hospital : absent or very 
nearly so. 

1846. New Orleans. Slightly epidemic. 

1847. New Orleans. Extended and violently epidemic. 

1848. New Orleans. Scarcely epidemic. 



SECTION III. 

LOCAL HISTORY. 

Under this head I propose to give some account of the origin and preva- 



192 THE PRINCIPAL DISEASES OP THE 

lence of yellow fever in the various places enumerated in the foregoing chart. 
I shall endeavor to ascertain, as far as may be practicable, from accounts 
which are very generally defective, and still more frequently conflict with 
each other, the circumstances, at each place, under which the fever has made 
its appearance. Prima facie, it might be supposed that a volume would be 
necessary to what is here proposed ; and so it would if authentic materials 
for an account of every invasion of the disease, in the places enumerated in 
the table, could be obtained ; but unfortunately they cannot, for in numerous 
instances the rise of the fever was not critically observed and registered at 
the time, and I feel quite certain that I have not been able to collect all the 
facts that have been recorded. In some instances, I have only been able to 
obtain the accounts of partisans on one side, and have not therefore the 
means of knowing what was suppressed, or what was unconsciously exagge- 
rated. 

There are three cities in which the disease has prevailed far more than 
all the rest taken together; these are Yera Cruz, Havana, and New Orleans. 

From the want of facts, I cannot attempt to give a history of its preva- 
lence in the two former ; but may remark that if the fever were originally 
imported, it has long since become endemic, and prevails every year, in all 
seasons, except winter. It is otherwise with the last, where it seldom reigns 
for more than four months, and in some years is entirely absent. 

In reference to the northern arc of the Gulf, New Orleans is, however, not 
more the commercial emporium, than the notorious haunt of yellow fever. 
In some years, the city only is visited, all the surrounding towns escaping; 
but it scarcely ever occurs in any of them without prevailing in it, and this 
unenviable pre-eminence suggests that the special histories should begin 
with that city. In giving them, reference will or may be made to the topo- 
graphical descriptions in Book First, which will not be here repeated. 



CHAPTER II. 

LOCAL HISTORY— NEW ORLEANS. 



SECTION I. 

CONDITION OP THE CITY — PREVALENCE IN. 

I. As New Orleans of all the towns north of Yera Cruz and Havana, is 
the one which has been oftenest scourged by yellow fever, a careful study 
of its topography, climate, police, commerce, and population, is indispensable 
to an inquiry into the origin of that fever. For the topography the reader 
is referred to the Article, New Orleans, Yol. I. Sect. III. Chap. Y. Part I. of 
Bk. I. (p. 97), where it will be seen, that a cypress swamp, into which the 



INTERIOR VALLEY OF NORTH AMERICA. 



193 



sewers and gutters of the city discharge their foul contents, presses hard 
upon one side of the city ; while on the opposite side, there is a large line 
of wharves and landings, for ships, steamers, and flat boats, rendering the 
batture, and sloping, submerged bank, exceedingly foul. It is on this side 
of the city that yellow fever generally makes its appearance. In referring 
to the topographical conditions which it has been affirmed are productive of 
yellow fever in other places, we find those of New Orleans every way answer- 
able to the demands of that hypothesis. 

II. Climate. — The climate of New Orleans may be estimated by data 
drawn from Part II. Book I. In collecting them, it is not necessary to go 
beyond summer and autumn, as the fever is nearly limited to those seasons. 
The following table embraces all that is necessary to show the temperature, 
winds, rainy days, and quantity of rain in the respective months of those 



Months. 


Mean 
temperature. 


Winds. Days. 


Rainy 
days. 


Rain in 

inches. 


Temperature at 
Havana ; for 
comparison. 


Southern. 


Northern. 


June, 

July, 

August, 

September, 

October, 

November, 


83-09° 

83-90 

83-27 

80-23 

71-69 

60-81 


15.7 
140 
12-7 
13-0 
10-7 
8-6 


3-4 

4-3 

11-4 

8-9 

14-7 

14-9 


7-7 
120 

9-0 
13-3 

4-3 

8-8 


3-182 
5-703 
4-466 
3-918 
3-926 
: 4-218 


84-12° 

84-30 

85-84 

83-04 

79-52 

75-56 



No observations have yet been published on the hygrometry of New Or- 
leans, but the study of its hydrography and its position in reference to the 
Gulf, will show conclusively, that the complement of its dew point must be 
small; that, in fact, its atmosphere is, at all times, like that of the adjacent 
Gulf, nearly saturated with vapor. 

In examining the table we find that a daily mean heat of 83° precedes 
for several weeks, the ordinary outbreak of fever ; but the disease acquires 
its greatest violence in September, when the temperature has fallen 3°, and 
often rages with severity in October, when the temperature has sunk 12°. 
Thus it is not the direct action of a hot atmosphere on the body which pro- 
duces the fever, though that action may predispose to it. 

During the months of June and July, in which the fever is generally de- 
veloped, the southern winds prevail greatly over the northern ; in August 
and September they approach much nearer to equality of prevalence ; in 
October the northern predominate j but the fever often continues violent in 
that month, when the northern winds are equal in prevalence to the south- 
ern in July. Thus, it is not the impress of the southern winds upon the 
body which awakens the fever ; and when it continues to prevail as an epi- 
demic after the northern winds have set in, they cannot be regarded as 
originating, simply as exciting it in the predisposed. 

The number of rainy days in July and August, during which the fever is 

VOL. II. 13 



194 THE PRINCIPAL DISEASES OP THE 

advancing to its acme, is twenty-one ; — the number in September, when its 
range is greatest, is larger than in either of the preceding months ; in Octo- 
ber, when the fever is declining, the number is much less. The quantity 
of rain is greatest in July — least in September ; yet the fever prevails more 
in the latter than the former, showing that whatever influence rain may 
exert is indirect. 

If we compare the temperature of New Orleans with that of Cuba, we find 
that in the months of June, July, August, and September, it rises above 
80° at each place. The average of the four is at New Orleans 82-62°, at 
Havana 84-32° — difference but 1-7°. Hence it appears that if a high tem- 
perature can directly or indirectly generate the fever in Havana, it may be 
so generated in New Orleans. The relation between such a temperature 
and the rise of the fever is rendered more obvious by referring to the mean 
temperatures of April and May, which in New Orleans are 73-71° and 
78-96°, while in Havana they are 78-98° and 83-58°. Now the fever does 
not occur at the former city in those months, but does prevail at the latter. 
A similar observation applies to the temperature of November, which at New 
Orleans, sinks as low as 60*81°, with a cessation of the fever, but in Havana 
it keeps up to 75-56°, and the fever continues to prevail, till it is arrested 
by a winter mean heat of about 70°. On the whole we are led to the con- 
clusion that a heat of 80° or upwards is necessary to the rise of the fever, 
but that having become prevalent, it will continue under a lower tempera- 
ture, than that which was necessary to its production. 

III. Commerce. — Being the great commercial city of the G-ulf of 
Mexico, New Orleans is visited by ships from nearly all parts of the world. 
They arrive at all seasons of the year, from most of the ports of the West 
Indies, but above all from Havana, where as we have seen the disease is 
either endemic, or a naturalized annual epidemic. From May to November, 
indeed, it is scarcely ever absent, and throughout that half the year ships 
after a short voyage are constantly arriving at the port of New Orleans. 
The same is true of the ports of the northeast coast of South America, of 
Central America, and Mexico ; above all of Yera Cruz, where the preva- 
lence of the disease is almost as constant as at Havana. When these ves- 
sels, like all others, arrive at one of the mouths of the Mississippi, they are 
detained a few hours or a day, to be piloted across the bar, and to show 
their clearances to the boarding officer, when they are immediately taken 
in tow by a steamer, and in less than a single day, are discharging cargo 
on the quay of New Orleans. 

Before the sale of Louisiana to the United States, which was consummated 
in 1804, the commerce of New Orleans was quite limited, but even then it 
was as great or proportionably greater than that of Havana, though in abso- 
lute amount much less than at the present time. After Louisiana became 
incorporated with the United States, the commerce of the city increased, 
except during two years, including a part of 1807 and 1809, when it was 



INTERIOR VALLEY OF NORTH AMERICA. 195 

suspended by the embargo. The declaration of war again suspended it in 
1812, and it was not revived till after the arrival of the news of peace in 
1815. Since that time, through a period of nearly thirty-five years, it has 
rapidly increased, without being suspended a single day; and as our table 
shows there have been in all that time, but two years in which the fever, 
either sporadic or epidemic, has not shown itself. In 1823 there were but 
two cases admitted into the Charity Hospital; in 1831, three cases; in 
1836, seven cases ; in 1840, two ; and, in 1845, one. From the first, the only 
quarantine was in the year 1821, when vessels from certain ports were re- 
quired to stop at the English Turn, eighteen miles below the city. 

Thus it appears that New Orleans is and has always been exposed, in an 
eminent degree, to whatever dangers there may be in commerce ; and that 
if the fever is transmissible by ships she must of necessity have been 
scourged by it many times. 

IV. Population. — It is well known that the victims of yellow fever are 
chiefly immigrants. For eighty-six years after its settlement, that is up to 
the period of the cession of Louisiana to the United States, the migration 
from Europe was so small that the whole population amounted only to 8000 ; 
and it appears from the general table that the fever but seldom prevailed. 
In the next thirty-six years up to 1840, the population increased to 191,102; 
indicating an immense immigration, and throughout that period, the fever 
has been correspondingly prevalent. But to show more conclusively the 
relation between immigration and the prevalence of the fever I will go into 
the following details : — 

In winter and spring a countless number of persons from the interior of 
the Valley visit New Orleans on business, or for pleasure, or through 
curiosity, but a very large majority of them leave it before the setting in of 
the sickly season. Nevertheless there is an annual autumnal addition to its 
population from other parts of the United States as well as Europe. The 
European immigrants, chiefly Irish and G-ermans, are generally poor ; and 
probably ignorant of the danger they incur thereby, embark at such times 
as to bring them to New Orleans in summer and autumn, no less than in 
winter and spring. Most of the G-ermans ascend the Mississippi, and a 
portion of the Irish, though considerable numbers remain. The evidence 
of all this is to be found on the books of the Charity Hospital. In 1844, 
it appears by the annual reports of the administrators of that most benevo- 
lent establishment, that in the preceding fourteen years, the number of its 
inmates had been 64,034, of whom only 625 were natives of Louisiana, and 
8604, or little more than an eighth part, natives of the United States. All 
the rest were foreigners. Of this class fifty per cent, were Irish, nearly 
fourteen per cent. G-ermans, ten per cent. English, eight per cent. French, 
and eighteen per cent, of various other nations. For the first twelve 
years of the period just named, the registers of the Hospital made no dis- 
tinction between old and recent emigrants, but in 1842-3 this was done, 



196 THE PRINCIPAL DISEASES OF THE 

three years being the term of distinction. In those two years the admit- 
tances numbered 9421, of which 7348 had been in the city less than three 
years. If we apply this ratio of about seventy-eight per cent, to the whole 
number, 64,034, we have 49,944, or a fraction less than 50,000, making 
an annual average of 3571, of patients who had been in the city less than 
three years. During the fourteen years nearly 7000 patients were admitted 
for yellow fever; and as, from what is well known of that disease, the whole 
of these may be assumed to have been of the 50,000 strangers who had 
resided in the city less than three years, we see that yellow fever carries to 
the hospital nearly a seventh part of all the new-comers who find their way 
thither. From the registers of the Institution, about one half of those who 
are admitted for that disease die, and consequently 3500 poor strangers 
have died in that establishment from yellow fever, in fourteen years. Of 
the number of cases or deaths from the fever in the private hospitals, and 
the practice of the physicians of the city during that period, I cannot speak ; 
but enough has been said, I think, to show that the chief havoc of the 
fever, is among the unacclimated. A large proportion of these patients are 
men (for comparatively but few women immigrate to New Orleans, espe- 
cially from Europe), and the majority of them are employed in the streets, 
and on the wharves about the shipping. Many of them, indeed, are boat- 
men, who descend the river in flat-boats in summer and early autumn. 

This account of the population of the city, shows that it fulfils the con- 
ditions considered requisite to the prevalence of the fever in those tropical 
countries where it seems to be naturalized, or is at least of annual preva- 
lence j that is, that it includes numerous strangers from higher latitudes, 
the majority being poor, and leading lives of exposure and dissipation. 



SECTION II. 

TIME OP COMMENCEMENT — AND PREVALENCE IN DIFFERENT YEARS AND 
MONTHS COMPARED WITH AUTUMNAL FEVER. 

I. Commencement and Mortality of the Fever in different 
Years. — The following table was principally compiled from data collected 
by a careful examination of the books of the Charity Hospital, in my second 
visit, 1844. Its object is to show the period of the year in which the fever 
begins, with the number of deaths compared with the number of admissions. 
A further object is to compare the admissions and deaths from autumnal 
fever, with those of yellow fever. Many of the earlier registers, not to go 
further back than the year 1818, were kept so imperfectly, that the table 
necessarily presents a number of blanks. 



INTERIOR VALLEY OF NORTH AMERICA: 197 

TABLE. 



YEARS. 


YELLOW 


FEVEE. 


AUTUMNAL FEVER. 


Date of the first twelve 
crises of Yellow Fever 


A.D. 


Admissions. 


Deaths. 


Admissions. 


Deaths. 




1818 


43 


Imperfect. 


Imperfect. 


Imperfect. 


Aug. 30 to Sep. 8. 


1819 


141 


tt 


tt 


<< 


May 7 to July 28. 


1820 


122 


«< 


(< 


cc 


July 21 to Aug. 9. 


1821 


None. 


None. 


None. 


«« 


None. 


1822 


349 


Imperfect. 


358 


(< 


Sep. 1 to 7. 


1823 


2 


2 


424 


58 


Aug. 23 to Sep. 11. 


1824 


176 


Imperfect. 


438 


22 


Aug. 4 to Aug. 26. 


1825 


92 


59 


283 


22 


June 23 to July 12. 


1826 


23 


5 


465 


34 


May 18 to July 11. 


1827 


388 


265 


449 


18 


July 19 to 30. 


1828 


305 


Imperfect. 


355 


Imperfect. 


June 18 to July 25. 


1829 


452 


it 


334 


n 


May 23 to June 18. 


1830 


416 


158 


679 


52, 


July 15 to July 29. 


1831 


3 





847 


Imperfect. 


June 9 to Sep. 13. 


1832 


36 


22 


534 


33 


Aug. 15, unknown. 


1833 


887 


449 


664 


69 


July 12 to Aug. 7. 


1834 


Imperfect. 


Imperfect. 


Imperfect. 


Imperfect. 


Aug. 28 to Sep. 30. 


1835 


505 


284 


2152 


135 


Aug. 23 to Sep.l. 


1836 


7 


5 


1430 


12 


Aug. 24 to Oct. 4. 


1837 


1194 


613 


1384 


28 


July 24 to Aug. 6. 


1838 


24 


Imperfect. 


Imperfect. 


Imperfect. 


Aug. 25 to Oct. 2. 


1839 


1086 


452 


1153 


20 


July 23 to Aug. 


1840 


1 





1890 


45 


July 25. 


1841 


1113 


594 


956 


30 


July 27 to Aug. 12. 


1842 


410 


214 


1323 


30 


July 30 to Aug. 23. 


1843 


1053 


487 


309 


26 


July 5 to July 29. 


1844 


150 


83 


1980 


76 




1845 


1 





1688 


11 




1846 


148 


89 








1847 










July 5 to July 17. 


1848 


1234 


420 









Several conclusions are deducible from this table. 

1. We find that yellow fever, for the twenty-five years preceding 1843, 
classing the years in which the number of admittances into the Charity 
Hospital did not exceed 7 with that in which none was received, was absent 
only 5 years. But although it is highly improbable that the disease could 
be sporadic in the city without any patient being sent to that establishment, 
still it may have happened, and therefore, it cannot be said with positive- 
ness that there was a single year of the twenty-five in which the disease 
did not occur to some extent. On the other hand it may be that the few 
cases which were received in four out of those five years were from ships, 
and had been generated elsewhere, which if true, would leave us a prevalence 
of twenty years out of twenty-five. Granting this, we find that while 
autumnal fever prevails every year, yellow fever occurs four years out of 
five — approaching in this respect to an endemic. 

2. In casting along the columns of admittances we find the numbers be- 
coming larger and larger, but this does not indicate an increasing preva- 
lence of either yellow or autumnal fever, but results from the constantly 



198 THE PRINCIPAL DISEASES OF THE 

augmenting population of the city. Indeed it is obvious, that in proportion 
to the population, the number of admittances from both diseases was less in 
the second than the first half of the twenty-five years ; from which, if it did 
not result from the increase of private hospitals, we may believe both fevers 
to be on the decline. 

3. Had a case in the month of May been reported in one year only, it 
might have been rejected as an error, but when we find that entry repeated 
twice in subsequent years, it seems necessary to admit the whole ; which we 
may do with the less hesitation as we find that it commenced three times in 
the month of June. Nevertheless we perceive, in reference to the month 
of May, that it was in the different years nearly twenty-six, fifty-four, and 
eighty-two days (average fifty-four days), before the first twelve patients 
were admitted ; and in reference to June, nineteen, thirty-seven, and ninety- 
six days (average fifty days) before that number were entered. In ten 
of the twenty-five years, that is forty per cent., the first admissions were in 
<Tuly, and the average number of days before the twelve patients were entered 
was seventeen. In eight years or thirty-two percent, of the whole term, the 
first admissions were in August, and the average duration of the time in which 
the first twelve were brought to the hospital was twenty-four days. In a 
single year only was the first admission delayed until September, when it 
occurred on the first day of the month, and by the 9th, twelve patients had 
been brought in. 

Thus we see that the time through which, in the twenty-five years, the 
first case occurred, was from the 7th of May to the 1st of September, a 
period of nearly four months. But July is the month in which not only 
the greatest number of invasions were made, but in which the early cases 
succeeded each other most rapidly. Next was August, nearly equal to it ; 
and then May, June, and September. The general fact then is, that the 
yellow fever of New Orleans begins chiefly in July and August — the hottest 
months of the year ; while in the South, autumnal fever begins, as is well 
known, in the latter part of April, or early in May, and is sometimes of epi- 
demic prevalence as early as June. 

If we examine the table to ascertain whether there is any connexion 
between an early or a late appearance of the Fever and its subsequent vio- 
lence or prevalence, we find none ; for, in some years, when it began early, 
it proved only sporadic, as in 1825, '26, and '31 ; while in others, as in 
1828, and '29 it was epidemic j and again in 1817, '23, '32, and '36 it began 
late, and prevailed but little ; while in 1822, '24, and '35, a late beginning 
was followed by epidemic prevalence. 

4. Years of sporadic and epidemic prevalence do not always alternate ; 
but in this respect there is great irregularity. In 1821 there was none, but 
in 1822 a mortal epidemic, to which succeeded four years of sporadic preva- 
lence, then four of epidemic prevalence, then two of sporadic, and then 
one of a remarkably epidemic character. From 1835 to 1843 inclusive, 



INTERIOR VALLEY OF NORTH AMERICA. 



199 



there was however a regular alternation ; though 1842 would have passed 
for a year of decided prevalence, had it not been placed between two, re- 
markable for their great mortality. The explanation usually and perhaps 
correctly given of these alternations, is that after a great epidemic there 
are but few susceptible persons to be acted upon — many have died — others 
have fled and do not return, and the tide of immigration has been temporarily 
checked. 

5. The table shows that different epidemics are not equally mortal. Thus 
in 1825, fifty-nine out of ninety-two, and in 1827, two hundred and sixty- 
five out of three hundred and eighty-eight died, but in 1830, only one hun- 
dred and fifty-eight out of four hundred and sixteen were left. In 1833 the 
deaths were within a fraction of half the admissions ; in 1837, they conside- 
rably exceeded half; but in 1839 fell far short of that proportion. In 
deducing a ratio of mortality from all the terms in the table, it may be stated 
at fifty per cent., or one half. This is undoubtedly a large proportion, but 
the patients are generally advanced in the disease, often indeed moribund, 
before they are sent to the hospital. Many of them in fact are taken there 
to die, that they may be buried at the public expense. 

Nothing in the table is more striking than the low rate of mortality of 
autumnal fever compared with that just given. It does not exceed five 
per cent., or a tenth part of the mortality of yellow fever. Thus if one hun- 
dred patients with the latter disease were taken there, fifty would die ; while 
of the same number affected with the former, there would be only five deaths. 

II. Relative Prevalence oe Yellow Fever and Autumnal Fever 
in the Different Months. — The following table compiled from the 
registers of the Charity Hospital, gives the average monthly number of 
patients with yellow fever and autumnal fever, for six years. In four 
of these years both diseases were epidemic ; in two of them yellow fever 
was absent, or slightly sporadic. 



Mean of 1839, '41, '42, '43. 
Both fevers epidemic. 

Yellow Fever, . . . 
Autumnal Fever, 


June. 


July. 


August, i Sept. 


Oct. 


Nov. 


Dec. 



62 


11 

182 


223 
159 


404 
108 


131 
124 


58 
135 


6 
91 


Mean of 1838-'40. 

Yellow Fever nearly absent. 
Yellow Fever, . . . 
Autumnal Fever, 



130 



225 


2 
207 


4 
254 


6 
259 


1 
136 



91 


United Averages. 

Yellow Fever, . . . 
Autumnal Fever, . . 



192 


11 
407 


225 

366 


408 
362 


139 
383 


59 
271 


6 
182 



1. This table is instructive. We see that August, September, and Octo- 
ber are the true yellow fever months ; but that the disease continues to 
occur in November. In the order of prevalence the months stand Septem- 
ber, August, October, November, July, December, and June. Taking the 



200 THE PRINCIPAL DISEASES OF THE 

years in which yellow fever was absent, the order of prevalence of autumnal 
fever was October, September, July, August, November, June, and Decem- 
ber ; but taking the years in which yellow fever was epidemic, the order of 
prevalence of autumnal fever was July, August, November, October, Sep- 
tember, December, and June. Thus, we see, that yellow fever exerts a dis- 
turbing influence on the prevalence of autumnal fever, by reducing the num- 
ber of cases in August, September, and October. This was so strikingly 
the case in one of the years, 1839, that I am tempted to present its results. 



Months. 


Yellow Fever. 


Autumnal Fever 


June, 


. . 00 


81 


July, 


.11 . 


. 146 


August, . 


.481 . 


65 


September, 


.360 . 


39 


October, . . . 


.129 . . 


88 


November, 


.62 . 


. 152 


December, 


.00 . 


. 131 



2. These statistics seem to indicate two distinct morbific influences, coexist- 
ing and operating at the same time, in the production of two forms of fever ; 
but is not this an assumption ? Do not both constitute but a single epi- 
demic, becoming, on the approach to the equinox, more malignant, and with 
this increase of violence, presenting some new symptoms ? An affirmative 
answer to this question would likewise be an assumption. Meanwhile we 
are bound to admit that, with due allowance for errors of diagnosis in the 
hurry of an epidemic, the cases which have been denominated yellow fever 
by the numerous experienced and intelligent physicians of the Charity Hos- 
pital, some of whom believe in the foreign and others in the domestic origin 
of that fever, were really different in their symptoms from those which were 
called autumnal fever — especially diverse in the phenomena which preceded 
death, in the post-mortem appearances, and in the ratio of mortality. Which 
facts being admitted, the question at once arises, why this difference ? and 
whether it does not imply the action of some modifying cause in conjunction 
with that which produces ordinary autumnal fever; and thus the aetiologi- 
cal inquiry only assumes a new direction. 

3. It appears that in the years embraced in the foregoing tables, there 
were more than half as many cases in December as in July ; yet we hear 
much more about yellow fever in the latter than the former of these months. 
The explanation is, perhaps, that the first cases occasion great alarm, and 
lead to exaggerated rumors of the prevalence of the fever ; but, after it has 
declined through November, and the panic has died away, the December 
cases occasion but little emotion in the public mind, and are often not 
noticed. If a few persons remain too long in the city after the month of 
June, a much larger number return too early, and are liable to be taken 
down, after the disease is supposed to be entirely gone. Finally, some of 
the cases in December are relapses. Of this kind, perhaps, are the occa- 



INTERIOR VALLEY OF NORTH AMERICA. 201 

sional cases in January and February, of which I found notices in the 
records of the Charity Hospital. In March and April an entry is here and 
there to be found ; but, on the whole, the first four months in the year are most 
exempt ; — or, to express the fact in a more comprehensive manner, we may 
say, that the fever occurs between the summer and winter solstices, and is 
most prevalent about the autumnal equinox — most entirely absent, about 
the vernal. Thus it never reappears in spring, after having been epidemic 
in autumn, in which respect it departs from the well-known law of autum- 
nal fever. 



SECTION III. 

ANNALS OF THE FEVER AT NEW ORLEANS. 

I. From the Beginning of the Town in 1717 to 1790. — In this sec- 
tion I propose to give such notices of the annual recurrence of the Fever 
in New Orleans, as a scanty supply of materials will permit. For the first 
hundred years after the settlement of the city no hospital records were kept, 
and it is quite impossible to find out with precision how many times it 
prevailed. 

As bearing on the question of the importation of the Fever from Africa, 
it may be stated, that on the first year after the settlement of the place, 
two shiploads of negroes, amounting to 500, were introduced.* Nothing is 
said, however, as to yellow fever. Fifty years afterwards, according to 
Norman,*f who does not, however, cite authority for the fact, the first visi- 
tation of the Fever followed on the arrival of a British vessel from the coast 
of Africa, with a cargo of slaves. Dr. Thomas fixes the first invasion of the 
fever in 1796, or twenty-seven years later. J This, however, is a mistake, 
as we shall presently see. Throughout the whole period, the commerce of 
the city was exceedingly limited; and up to the year 1788, seventy years 
after the first settlement, the population amounted only to 5338, including 
negroes. On the whole we may conclude, that thoughout the period men- 
tioned the town suffered but little, if at all, from that malady. Since the 
year 1790, it has become gradually more and more frequent and formi- 
dable ; but through the first twenty-seven years, the accounts of its invasions 
are meagre and unsatisfactory. 

II. Season of 1791. — The first invasion of the Fever of which I have 
an authentic account, was in this year. My informant, Richard Relf, Esq., 
one of the most venerable citizens of New Orleans, soon after his arrival 
experienced an attack ; and. three of his fellow-lodgers fell victims to the 
Fever. After his recovery he saw many cases, and, in subsequent years 

* Martin's History of Louisiana, vol. i. p. 210. f New Orleans and Environs, p. 62. 

% Essai sur la Fieyre Jaune d'Amerique, p. 70. 



202 THE PRINCIPAL DISEASES OF THE 

became so familiar with it, that he could not be mistaken as to the charac- 
ter of the disease. There was no suspicion of its having been imported. 

III. Season of 1796. — Of the origin of this epidemic, Dr. Thomas* has 
given the following account : — 

" It is said that yellow fever had never been observed in New Orleans 
before 1796. Up to that time the city was of no great extent, and was sur- 
rounded by trees, which by their shade, prevented the putrefaction of the 
water covering the ground at their roots, and which absorbed to a great 
degree (a quality which they are known to possess) the deleterious miasm. 

" The Spanish baron, Carondelet, then governor of Louisiana, caused a 
number of works to be executed about this time, of which the principal were, 
1st. The construction of a canal two miles long, which still bears his name, 
and terminates in New Orleans in a basin — (large enough to contain a great 
number of small vessels of from 25 to 100 tons burden, dug exactly in the 
place in which the old cemeteries were situated) — and at the other end, in 
a small river emptying into Lake Pontchartrain. 2d. Fortifications, sur- 
rounded by ditches. 3d. A clearing away, for a considerable distance, of 
the trees which surrounded the city. This laid bare a considerable extent 
of marshy land, which, dangerously influenced by the solar heat, soon 
disengaged pestiferous effluvia in abundance. 

" These works, and particularly the canal, were finished in 1796, as is 
shown by the records of the city, from which I have obtained these details ; 
and it is exactly at this time that the first epidemic of yellow fever occurred, 
which carried off, at its ioception, almost all the laborers engaged on the 
works, as eye-witnesses testify. 

" The disastrous results of disturbing the soil have been demonstrated 
anew, in the epidemic of Natchez, in 1819. Dr. Prouens, a well-educated 
physician, who practises medicine there, wrote on this subject to the Medical 
Society of New Orleans (of which he is a correspondent), that the obvious 
cause of this epidemic, was not an importation of it by the river, as the 
contagionists pretend ; for the malady began to show itself in a place quite 
remote from the port, and in the immediate vicinity of some very consi- 
derable excavations, which had been made a short time before for the purpose 
of levelling the streets. 

" The old inhabitants of St. Domingo have assured me, that many ana- 
logous examples were known to have occurred in that island from the same 
cause. 

" It will be seen (further along), in reading the description of the epi- 
demic of 1822, that excavations of the earth may be considered as one of 
the causes which fixed its limits." 

The opinion that the Fever was of local origin seems at that time to have 
been controverted ; for the late Prof. Carpenter, -f copying from the Louisiana 

* Essai sur laFievre Jaune, p. 70. t Sketches from the History of Yellow Fever, p. 13. 



INTERIOR VALLEY OF NORTH AMERICA. 203 

Courier for November, 1820, says, " It was traced to a vessel which had 
brought it." 

IV. Season of 1799. — Prof. Carpenter,* again copying from the paper 
just quoted, says there was " what was considered proof of its importation." 
I have been informed by Mr. John McDonough, who arrived the year before, 
that it prevailed violently ; and was then spoken of as a disease of constant 
annual recurrence. 

V. Season of 1800. — The only notice I have seen of this year, is in a 
(parenthetical) sentence of Dr. Barton's paper, on the Epidemic of 1833, 
which represents the Fever as having constituted a " great" epidemic ; and 
that easterly winds prevailed for three months.")" 

VI. Season of 1801. — Mr. Maunsel White, who came to the city in 
this year, has informed me, that he had the Fever, and knew of many fatal 
cases. 

VII. Season of 1804. — This was the first autumn after the transfer of 
Louisiana from France to the United States. The population of the city 
had, as yet, risen only to 8,000. Prof. Carpenter merely refers to its 
existence ; J but I was informed by Mr. McDonough, that it prevailed with 
violence. 

VIII. Seasons from 1807 to 1816 inclusive. — I have thrown these 
ten years into one group, because the commercial intercourse between 
New Orleans and the more southern cities of Havana and Vera Cruz was 
more or less interrupted, first by an embargo, and second, by the war with 
Great Britain. The following table presents the results of a diligent inquiry 
into the history of the Fever in those years. 

1807, embargo, yellow fever, none. 

1808, " " none. 

1809, no embargo, " prevailing. 

1810, " " none. 

1811, " " prevailing. 

1812, war, " prevailing. 

1813, " " none. 

1814, " " none. 

1815, no war nor embargo, li none. 

1816, " " none. 

I have not been able to find any evidence of the occurrence of the Fever 
in the seven years of this table which are marked as exempt. It will be 
observed that in five of those years, there was neither embargo nor war, 
in two there was an embargo, in three war. Of the three years in which 
the Fever prevailed, two were without embargo or war, and one with war. 
For these visitations we have the following authorities. 

A.D. 1809. Prof. Carpenter§ notes it as occurring. Dr. Huestis|| speaks 

* Sketches from the History of Yellow Fever, p. 14. f American Journal, vol. xv. p. 34. 

t Ibid, p. 15. § Ibid, p. 17. H Topography and Diseases of Louisiana, p. 89. 



204 THE PRINCIPAL DISEASES OF THE 

of yellow fever in connexion with scurvy among the troops stationed at Terre- 
aux-boeufs, fifteen miles below New Orleans. But as he regarded that 
fever as identical with autumnal remittent fever, his notice is not conclu- 
sive. I have been informed, however, by Alfred Hennen, Esq., who reached 
the city in that year, that yellow fever certainly did prevail ; a statement 
confirmed by Mr. C. W. Dewey. 

A.D. 1811. My authorities for the prevalence of the Fever this year are 
Mr. McDonough, Mr. Hennen, and Mr. "William Flowers, all most reliable 
observers. The last of these gentlemen informed me that the Fever was 
ascribed by many to an extensive breaking up of the streets preparatory to 
paving them. Prof. Carpenter notes its occurrence, but is silent as to its 
cause.* 

A.D. 1812. Dr. Huestis, in the work just quoted, p. 117, writes : " Three 
companies of the first regiment of artillery were then stationed at the 
barracks in that city, of whom a great portion died with the yellow fe^er 
and from the effects of mercury." To this explicit statement, I may add, 
that Judge Chamberlain of Mobile informed me, that he himself expe- 
rienced an attack of the fever in the autumn of that year, being then a new- 
comer in New Orleans. The suspension of commerce consequent tm the 
declaration of war, gives importance to these statements ; which conflict 
with those of Prof. Carpenter, who informs usf that there was no yellow 
fever in the city this year. According to the recollection of Mr. Maunsell 
White there was none. I have placed 1808 among the years of exemption, 
but ought to state, that Mr. C. W. Dewey assured me that the fever did 
occur in that year. 

A.D. 1816. In connexion with the absence of the fever this year it is 
proper to place the following extract from a report of a committee of the 
Societe Medicale de la Nouvelle Orleans.^ 

" The year 1816 was signalized by a rupture of the banks of the river, 
followed by an inundation of nearly the whole region between the left bank 
of the river and Lake Pontchartrain. This event occurred at the opening 
of spring, and the waters remained on the surface more than six weeks, 
leaving on its surface when they drained off a thick deposit of slime; never- 
theless, notwithstanding the heat which afterwards prevailed, the season 
was one of the most salubrious." 

IX. Season of 1817. — This year of fever was fatally epidemic. Accord- 
ing to Prof. Carpenter§ it was introduced from Havana ; whence a British 
vessel arrived on the 18th of June, with cases of the fever. But it 
did not spread into the city. On the 10th of July, another vessel reached 
New Orleans from the same port, with many cases on board ; the disease, 
however, did not become epidemic till after the middle of that month ; that 

* Sketches from the History of Yellow Fever, p. 17. t Sketches, p. 17. 

% Journal de la Soc. Med. No. 4, p. 157. § Ibid. p. 17. 



INTERIOR VALLEY OP NORTH AMERICA. 205 

is, four weeks from the time of the first arrival. Prof. Carpenter's authority, 
is the New Orleans Gazette. 

In a report by a committee of the " Societe Medicale de la Nouvelle Orleans" 
on the epidemic of 1819, reference is made to that of 1817, which is repre- 
sented to have begun early in the month of May, becoming epidemic in July 
and terminating in October. This report was read in the presence of the 
mayor of the city, and approved by the Society. Hence public opinion was 
divided as to the origin of the fever in that year. Nevertheless in the fol- 
lowing winter the legislature passed a quarantine law. 

X. Season of 1818. — Notwithstanding the quarantine directed by the 
law of the previous winter, forty-three patients were admitted into the 
Charity Hospital, the first being on the 30th of August; Prof. Carpen- 
ter, however, is silent concerning the occurrence of the fever this year. 
This fact explains why the legislature in the following winter repealed the 
quarantine. 

XL Season of 1819. — This year the fever was highly epidemic and 
malignant. According to Prof. Carpenter,* quoting the New Orleans 
Gazette, several vessels arrived from Havana, with cases of yellow fever, in 
June, and about the 1st of July cases occurred on the ships lying in port. 
The Governor, in virtue of a discretionary power, then proclaimed a quaran- 
tine, but it was not enforced. As I ascertained by the books of the Charity 
Hospital, 141 cases were admitted into that establishment, the first being on 
the 7th of May; but up to the 28th of July, only twelve patients had been 
received. The Committee of the Societe Medicale (p. 7), already quoted, 
give the same date for the first case j adding, that it proved fatal, and that 
the fever continued to occur sporadically till the 1st of August, when it 
became epidemic ; and did not cease till December. 

XII. Season of 1820. — The admissions into the Charity Hospital this 
year were 122 ; the first being on the 21st of July ; but it was the 11th of 
August before twelve cases were admitted. Prof. Carpenter]" assigns the 
20th of July as the commencement of the fever, which, he says, did not 
become epidemic till near the middle of August. On the 17th of June, 
according to the same writer, a vessel arrived from Havana, having lost two 
men from the fever on her voyage. On the 10th of July another came into 
port, from Matanzas, with cases of the fever on board. In the following Feb- 
ruary, 1821, the legislature re-enacted a code of quarantine regulations. 
The following season was exempt ; as no case was admitted into the Charity 
Hospital. 

XIII. Season of 1822. — The hospital admissions this year were 349, of 
which the first twelve were from the 1st to the 7th of September. Accord- 
ing to Prof. Carpenter,J who quotes a report of the Board of Health to the 
legislature, in January, 1823, the fever was introduced by two sloops from 
Pensacola, which came into the city by Lake Pontchartrain and the Bayou 

* Sketches, p. 18. fim. p. 19. t Ibid. p. 23. 



206 THE PRINCIPAL DISEASES OF THE 

St. John. They left Pensacola on the 21st of August, as soon as the fever 
began to prevail in that town. Some of the passengers died on the voyage, 
and the others dispersed themselves over the city. The same author also 
informs us, on the authority of the health officer, that persons were permit- 
ted to escape from vessels lying at the quarantine ground, and come into the 
city. The first appearance of the fever, as late as the 1st of September, 
certainly favors the theory of importation from Pensacola; yet, in several 
other years, it did not appear till the last week of August. 

XIV. Season of 1823. — As the fever prevailed this season with great 
mortality at Natchez, it is important to inquire if it also prevailed in New 
Orleans. On this point Dr. Monette, of Natchez, has published the follow- 
ing statement : "New Orleans, this summer, was not unusually sickly until 
the 1st of August, although some cases of yellow fever had previously oc- 
curred. About the middle of August cases multiplied rapidly, and that 
city suffered severely for two months."* This was published in 1838. In- 
1842, the same gentleman says of the same fever, " Many cases occurred 
among the ships' crews, and others, about the wharves, as early as July, and 
it became epidemic about the first week of August." Apparently bor- 
rowing from the Natchez historian, Prof. Carpenter, without quoting any 
authority or being in New Orleans at the time, says, " Cases occurred first 
among the shipping in the harbour, in the month of July, and the disease 
became epidemic early in August."f But Dr. Thomas, who was in the city, 
declared to me that, positively, the fever was entirely absent that year, and 
in a careful examination of the books of the Charity Hospital, I could find 
but two cases reported, one on the 23d of August, the other on the 11th of 
September. It seems impossible that the fever should have been epidemic 
without affording more cases to the Hospital, seeing that its victims belong 
chiefly to the class of persons who, when ill, rely on that Hospital for relief. 
It is certainly desirable to the cause of truth that these discrepancies should 
be reconciled. 

XV. Season of 1824. — The admissions into the Charity Hospital this 
year were 178, the first being on the 4th of August. Prof. Carpenter J 
informs us that it was introduced by the boats which towed up infected 
vessels from the Balize to the quarantine ground. Having occasion to in- 
spect the books for this year, of the surveyor of the port, I found that in 
the month of June, beginning on the 9 th, twelve vessels arrived from yellow 
fever ports of the G-ulf, and in July five others, yet no case was sent to the 
Hospital till the 4th of August, and only nineteen cases in that month, 
leaving 159 cases for the remainder of the season. It seems remarkable, on 
the theory of importation, that the arrivals in June and July should not 
have introduced the fever. 

XVI. Season of 1825. — The admissions into the Hospital this year 

* Essay on the Epidemic Yellow Fever of Natchez, p. 61. f Sketches, p. 25. 

t Quoting " Documents in relation to the introduction of the Yellow Fever into New Orleans in 1824." 



INTERIOR VALLEY OF NORTH AMERICA. 207 

amounted only to ninety-two; and consequently it was scarcely epidemic. 
The first case occurred on the 23d of June. Prof. Carpenter recognises its 
existence, without offering any explanation; and Dr. Monette does not 
refer to it. 

XVII. Season of 1826. — The number of cases sent to the Hospital this 
year amounted only to twenty -three ; and consequently it was but sporadic. 
The first was on the 18th, the second on the 26th of May. Both Dr. 
Monette and Prof. Carpenter are silent concerning this sporadic prevalence. 

XVIII. Season of 1827. — The first case was sent to the Charity Hos- 
pital on the 19th of July, and the books of that establishment report 388 
cases j a larger number than had ever before been admitted in one season ; 
yet Prof. Carpenter says nothing of its occurrence ; and I have not been 
able to find any account of its origin. 

XIX. Season of 1828. — The admissions this year were 305. The first 
patient was a sailor from Havana, admitted on the 18th of June. It was 
not till the 25th of July that twelve cases were admitted. Both Prof. Car- 
penter and Dr. Monette again are silent as to this epidemic. Concerning 
its origin, I have no information but that derived from the registers of the 
hospital. 

XX. Season of 1829. — Prof. Carpenter recognises the Fever as being 
epidemic this season, but gives no information concerning its rise or progress. 
The Hospital register gives two cases in May, and twelve cases by the 17th 
of June, The whole number of admissions into the Hospital was 452. Dr. 
Monette* says it did not become epidemic till the 24th of August ; but Dr. 
Gr. W. Campbell, of New Orleans, assured me, that it was epidemic four weeks 
before that time. According to that gentleman, it appeared in different parts 
of the city simultaneously ; and public opinion was adverse to its having 
been imported. The first nine cases in the practice of Dr. Meux, occurred 
within four days of each other, in various parts of the city. 

XXI. Season of 1830. — Prof. Carpenter says nothing of the Fever in 
New Orleans this year ; but the books of the Charity Hospital record 416 
cases, the first of which was on the 24th of July. Dr. Fennerf has 
stated the number at 256. I am unable to account for this discrepancy ; 
except by supposing that he depended on returns given him by some inac- 
curate clerk of the Hospital. My own results were from personal counting 
on the registers ; but if we adopt the lower number we still have indubi- 
table evidence that the Fever was epidemic that year, notwithstanding the 
silence of Prof. Carpenter, who has perhaps accidentally transposed this 
year and the next. 

XXII. Season of 1831. — The books of the Hospital report but three ad- 
missions, of which the first was on the 9th of June. Prof. Carpenter speaks 
of the Fever as being epidemic, perhaps meaning the last year. 

XXIII. Season of 1832. — The number of admissions into the Hospital 

* Essay, p. 74. t New Orleans Med. Journal, vol i. p. 103. 



208 THE PRINCIPAL DISEASES OF THE 

was 36; first case, August 15th. Prof. Carpenter is silent in reference 
to the Fever. The late Prof. Harrison has published that the Fever was 
epidemic ;* and Dr. Halphen had previously done the same.f The first in- 
vasion of Epidemic Cholera was made this year — the first case occurring, 
according to Dr. Halphen, on the 2t5h of October. Many cases of yellow 
fever, I was assured by physicians of the city, were reported at the Hos- 
pital as cases of cholera. 

XXIY. Season of 1833. — Prof. Carpenter indicates the Fever as epi- 
demic. The number of admissions into the Hospital was 887, the first case 
being on the 12th of July. Prof. Harrison says it was violently epidemic. 
Dr. Campbell informed me that he saw a case on the 25th of June. Accord- 
ing to Prof. Harrison there were occasional cases of cholera this season ; and 
Dr. Barton observed the same thing. J According to that gentleman, monor- 
rhagia and swellings of the inguinal ganglia in men, were frequent before 
the onset of the epidemic ; there was also much sickness among horses, cows, 
and hogs, in the surrounding country. Dr. Barton, the historian of this epi- 
demic, says nothing of importation, in which he is a disbeliever. Prof. Stone 
informed me that he was a resident physician of the Charity Hospital during 
this epidemic, and that nearly all the officers of the house were, like him- 
self, unacclimated. The fever commenced near the river, and in the latter 
part of autumn prevailed among the inhabitants in the neighborhood of 
that establishment. It was crowded with yellow fever patients throughout 
the season, yet the officers, who did not go out into the city, remained exempt, 
till the people near the Hospital were invaded, when it fell upon the officers 
of the establishment. 

XXV. Season of 1834. — Profesor Harrison marks this as an epi- 
demic season, but Professor Carpenter says nothing of it. The number of 
admissions into the Hospital was only 150, but the record is imperfect. 
The first case was on the 28th of August. Cholera was sporadic. 

XXVI. Season of 1835. — Professor Carpenter says nothing of the fever 
this year, but Professor Harrison represents it as a mild epidemic. Yet 
the number of cases in the Charity Hospital was 505, the first being on the 
23d of August. According to the latter historian, sporadic cases of cholera 
still occurred. 

XXVII. Season of 1836. — Prof. Carpenter does not speak of the fever 
this year. Prof. Harrison says there were a very few cases. The records 
of the Hospital show seven, of which the first was on the 24th of August. 

XXVIII. Season of 1837. — A year of great prevalence, 1194 patients 
being admitted into the Hospital. The first admission was on the 24th of 
July. Prof. Harrison calls it a violent epidemic. Dr. Campbell informed 
me that he visited patients through nine miles along the left bank of the 

* New Orleans Med. Jour. vol. ii. p. 131. 

•j- Mem. sur le Choi. Morb. Complique d'une Epid. de Fiev. Jaune in 1832, par Michel Halphen, M.D. 

t Account of the Epidemic Yellow Fever in 1833 ; Amer. Jour, of the Med. Sci. vol. xv. p. 30. 



INTERIOR VALLEY OF NORTH AMERICA. 209 

river. It was, however, the mildest epidemic he had known*; but the deaths 
in the Charity Hospital were up to the average mortality. Prof. Carpenter* 
says the first cases occurred on board of vessels from the West Indies. It 
deserves to be recorded, that this is the first year since 1824 that Prof. Car- 
penter has assigned an origin for the fever, though between that year and 
the present, it was, as we have seen, epidemic nine times, but four of which, 
moreover, are mentioned by him. As he was a gentleman of extensive re- 
search, and believed in the importation of the fever, it may be presumed 
that facts going to establish its introduction during that period, could not 
be found. 

XXIX. Season of 1838.— This year the fever was only sporadic. 
Twenty-four cases were received into the Charity Hospital — the first on the 
25th of August. Prof. Harrison says there were a " few cases/ 7 

XXX. Season of 1839. — A year of violent prevalence. The number 
of admissions into the Hospital was 1086 — the first on the 23d of July. 
Professor Carpenterj" says — " Introduced from Havana. " We are informed 
that the first cases occurred on board Havana vessels, and that the fever was 
during some time confined to the shipping. It was epidemic about the 
middle of August. " An extended report was made on this epidemic by 
Drs. Bahier, Fortin, Daret, and Sabin Martin, J believers in the local origin 
of the fever, who do not refer to the fact mentioned by Prof. Carpenter, but 
declare, that we are profoundly ignorant of the cause of yellow fever. 

XXXI. Season of 1840. — But two cases were admitted into the Hos- 
pital this year, and Prof. Harrison, has indicated it as a year of perfect 
exemption. The alternation of years of exemption and epidemic prevalence 
is more obvious in this period of the chronology of the fever, than any other. 
Thus it was epidemic in 1835 — nearly absent in 1836 ; greatly epidemic in 
1837 — barely sporadic in 1838 ; strongly epidemic in 1839 — almost un- 
known in 1840 j violently epidemic, as we shall see, in 1841 ; moderately 
epidemic in 1842; and extensively epidemic in 1843. 

XXXII. Season of 1841. — Admissions into the Hospital, 1113 — first 
case, July 27th. Prof. Carpenter§ says — introduced from Havana. It is 

well remembered in the city, that the first cases were on board the , 

from the West Indies, and it prevailed some time among the shipping, be- 
fore it became epidemic in the city. Prof. Harrison calls it a " violent 
epidemic, " but says nothing of its origin. Dr. Jones assured me that this 
was a " searching epidemic, " and that many persons who had passed through 
all seasons of fever untouched were attacked, and also, that it seized upon 
women more than it had done before. His first patient was a lady, who 
had kept at home for some time, lived three squares from the shipping, and 
was attacked before any one on board the ships. To this I may add from 
Dr. Thomas :|| 

♦Sketches, p. 26. t Sketches, p. 27. 't Jour, de la Soc. Med. No. 4. 

§ Sketches, p. 29. Relat. de l'Epidemie de Fievre Jaune, 1841, p. 7. 

VOL. II. 14 



210 THE PRINCIPAL DISEASES OF THE 

" It is an important remark, that, contrary to previous experience, the 
epidemic at first prevailed more among women than among men. For ex- 
ample, the first six patients whom I visited (between 30th August and 13th 
September), were all of the female sex ; and I ascertained that the experience 
of my professional brethren was nearly the same. Now it is well known 
that ordinarily the case is just the reverse. Why this change ? I do not 
know; as I saw no plausible reason, in 1841, which did not exist during the 
preceding epidemics. 

" By a sort of compensation the malady was habitually less severe on 
females. Later in the epidemic the proportion of male patients increased ; 
so that this anomaly existed only in the beginning/' 

XXXIII. Season of 1842. — The Hospital books give 410 for this year, 
the first case being on the 30th of July. Professor Carpenter* informs us 
that the first case occurred among the shipping from the West Indies and 
Mexico, and it continued to prevail among the shipping for some time be- 
fore it spread through the city. 

XXXIV. Season of 1843. — According to Prof. Harrison, this epidemic 
was not of the most extensive or violent kind; yet 1053 were admitted into 
the Hospital — the first on the fifth of July. Prof. Carpenter states that " all 
the first cases that occurred, were persons who had arrived in vessels from 
Havana, Vera Cruz, &c. Those who saw the first cases were satisfied that 
its source was foreign. It became epidemic early in September. " Dr. 
Meux informed me that as early as the 31st of July, when but twenty patients 
had been sent to the Charity Hospital, he had a case near the Water-works, 
in a woman who seldom went abroad. 

XXXV. Season of 1844. — The fever this year was moderately epidemic. 
The cases taken to the Charity Hospital numbered 150, of which eighty- 
three proved fatal. The whole number of deaths in the city was 148. "j* 

XXXVI. Season of 1845. — Nearly if not altogether exempt. The 
books of the Charity Hospital present but one case of (so called) yellow 
fever. It proved fatal; and the general bill for mortality of the city gives 
but a single death from that disease.J Yet I was assured by Dr. Mercier 
that a few cases did occur in the practice of several physicians. 

XXXVII. Season of 1846. — Extensively sporadic, or lightly epidemic, 
cases appearing in various parts of the city, and not traceable to any central 
focus. § Admissions into the Charity Hospital, after the 1st of September, 
148, and 89 deaths. 

XXXVIII. Season of 1847. — The visitation of this year was one of the 
severest which the city had ever experienced. The aggregate number of 
deaths, as reported from the cemeteries, was 2306 ; but this number was 
supposed not to include the whole. In September alone the number was 
1044. The greatest number for a single week, that ending September 5th, 

* Sketches, p. 29. Ibid. p. 30. t New Orleans Med. Jour. vol. i. No. 4. 

X Ibid. No. 5. § Ibid., vol. iii. No. 3. 



INTERIOR VALLEY OF NORTH AMERICA. 



211 



was 435. The first ten cases admitted into the Charity Hospital were from 
the 5th to the 17th of July. They occurred in various parts of the city. 
On the 2d of August, the Board of Health declared the fever epidemic. 
On the 18th of October, it had lost that character, and the Board pro- 
nounced it safe for those who had fled from the city to return. The 
weather, however, was still warm, and continued so till in November. 
Great numbers of troops returned, sick, from Vera Cruz during the sum- 
mer and early autumn. Very few of them, however, had yellow fever. 
Many of those who had, were received into the Luzenburg private hospital, 
but did not communicate the fever to its inmates. As in 1837, the fever 
extended up and down the river from Carrollton to the United States Bar- 
racks (see PL V.). Although the number of deaths was great (amounting, 
it was believed, to 3000, including those in the Fauxbourg Lafayette), the 
proportional mortality was not high, for the number of cases was immense. 
The following table presents the ages of 2460 of the victims : — 



Under 1 yeaT, . . 


3 


From 50 to 60 years, . 


. 103 


From 1 to 10 years, 


. 81 


" 60 to 70 " '. . 


. 46 


" 10 to 20 " . 


. 186 


" 70 to 80 " . . 


. 14 


" 20 to 30 " . 


. 1098 


" 80 to 90 « . . 


3 


" 30 to 40 " . 


. 671 


" 90 to 100 " . . 


2 


" 40 to 50 " . 


. 250 







Many of the children were natives of the city. A large number of per- 
sons who had experienced previous attacks were now taken down a second 
time. Many who had resided fifteen or twenty years in the city without 
suffering, were now attacked for the first time, and not a few new-comers 
escaped.* 

XXXIX. Season of 1848. — Barely epidemic. 1234 cases admitted 
into the Hospital : deaths, 420. This mortality was unusually low.f 



CHAPTER III. 



LOCAL HISTORY- 



-PLACES EAST AND SOUTHEAST OF THE DELTA OF 
THE MISSISSIPPI. 4 



SECTION I. 

THE BALIZE. 

I. The position of the Balize maybe seen on PI. V.,and its topography in 
Vol. I. Bk. I. Pt. I. Ch. V. Sect. II. Although the greater number of ships 
from New Orleans leave the Mississippi through the Southwest Pass, the 

* See Dr. Fenner's excellent history of this epidemic, New Orleans Med. Journal, vol. v. No. 2. 
f Ibid. toI. v. No. 5: 



212 THE PRINCIPAL DISEASES OF THE 

larger number enter it by the Southeast Pass, on which the Balize Village 
is situated. Two or three pilot-boats are generally kept cruising off the 
mouth of the Pass, and when a ship heaves in sight, a pilot is put on board. 
When it approaches the bar it comes to anchor, and is taken in tow by a 
steamer, in doing which there is of necessity more or less communication 
with it. Having been dragged over the bar, if from a port out of the 
United States, it is again brought to anchor, till its papers are examined by 
the boarding- officer, after which it is allowed to proceed. In some instances 
no steamer is present to tow it up to New Orleans, and in others a bargain 
is not immediately made, and thus vessels are detained in the mouth of the 
river, near the residences of the pilots. In all cases, when the tow-boats 
come down from New Orleans while the fever is prevailing in that city, 
there is intercourse between them and the pilots. Finally, there is a steam 
packet-boat which plies regularly between the two places. Hence the pilots, 
their families, and operatives, are not more exposed to all that can be deve- 
loped from the soil of their peculiar locality, than they are to whatever be- 
longs to ships from the ports of the Grulf and the tow-boats from New Orleans, 
while in latitude, the village is nearly a degree south of that city. 

II. Of the Fever. — Under such circumstances, whatever may be the 
origin of the disease, we should & 'priori expect to find it a great scourge of 
this little population, and yet it appears to be a rare visitor, and is not 
regarded with the least concern. In my numerous inquiries, through a 
sojourn of ten days, I met with no one who spoke of it as having been epi- 
demic ; while every one favorably contrasted the Balize with New Orleans 
in reference to the fever. Some of those with whom I conversed, as Capt. 
Taylor, the boarding-officer of the port, had resided there many years, and 
others who visit the place every week, as Capt. Annable, master of the tow- 
boat Phoenix, assured me that the yellow fever here was nothing compared with 
what it is in the city. But there is professional testimony to the same point. 
The physician of the Balize, Dr. Van Antwerp, arrived at that place in the 
month of October, 1839. In that autumn, as we have seen, the fever was 
more extensively prevalent in New Orleans, than it had ever been before, 
and continued so late, that sixty-two patients were received into the Charity 
Hospital in the month of November; in 1841, 1113- patients were taken to 
the Hospital, and in 1842, 410 ; yet, up to the time of my interview with 
him in February, 1843, he had seen but four cases of yellow fever, and they 
occurred in different years. Two of them, as far as he could find out, origi- 
nated in the place ; a third was in an oysterman, who gathered oysters on 
the coast north of the Balize, and said he had not visited the city; the 
fourth was in a young man who had made a voyage to New Orleans when 
the fever was prevailing there. 

As a negative proof of the exemption of this place, I may state that Prof. 
Carpenter does not mention it, although he wrote to prove the transmissi- 



INTERIOR VALLEY OF NORTH AMERICA. 213 

bility of the fever, and would certainly not have omitted to note its epi- 
demic prevalence at a place so exposed to the influence of ships. 

As this is the spot where ships from Havana and Vera Cruz, and tow- 
boats from New Orleans meet, there may be many cases of yellow fever 
contracted elsewhere, developed here, which must not be confounded with 
those which occur in the resident population of the Balize. 



SECTION II. 

MILITARY POSTS. 

I. Forts St. Philip and Jackson. — The situation of these forts may 
be seen in PI. V. They have been notorious for autumnal fever, but I 
have not met with any evidence of a single invasion of yellow fever. 

II. Fort Wood. — The plate just mentioned will show the position of 
this post, which always maintained an unabated intercourse with New Or- 
leans. Notwithstanding this, it has never been invaded by yellow fever. 
The Army returns, down to 1838,* show the fact, and Dr. Dalton, formerly 
Assistant Army Surgeon, but now of that city, informed me, that in 1829, 
when the fever was epidemic in the city, intercourse with the fort was not 
suspended, yet no case occurred at the post. It deserves to be mentioned, 
however, that in the autumn of that year the troops were temporarily trans- 
ferred to Shieldsborough, where the fever broke out among them. It can 
of course never be known whether that would have happened if they had 
remained at Fort Wood. 

III. Fort Pike. — A reference to PI. V. will show the position of this 
post. Dr. Dalton was stationed in it for three years, during which there 
was no yellow fever, although the intercourse with New Orleans was una- 
bated ; and the Army Register tells us, that from the establishment of the 
post, in 1811, down to 1838, the fever had not occurred there. f 



SECTION III. 

CIVIL STATIONS BETWEEN NEW ORLEANS AND MOBILE. 

I. Bay of St. Louis. — This is one of the places to which the unaccli- 
mated inhabitants of New Orleans escape when the fever begins to prevail 
in that city : still, it has not been without its visitations ; but whether the 
disease was confined to those who had been acted on by the remote cause 
before they started, is not quite clear. 

1. Season of 1820. — Dr. Merrill| states, that a detachment of troops 
had descended the Mississippi River, and were detained in New Orleans till 

* Statistical Report of Sickness and Mortality, U. S. Army. t Ibid. p. 207, 274. 

t Army Register, p. 20. 



214 THE PRINCIPAL DISEASES OF THE 

after the fever, which began that year on the 21st of July, had become pre- 
valent. On the 20th of August, they arrived at Shieldsborough, west side 
of the Bay of St. Louis, and twelve hours after landing a soldier, who had 
been attacked on the voyage, died with black vomit. Within twenty-four 
hours afterward, five more were attacked with the same symptoms, of whom 
two died on the third day. It soon became general among them. Dr. Mer- 
rill does not say in his official report whether the disease attacked any others 
than the soldiery ; but in conversation with him at Natchez, in 1844, he in- 
formed me, that the French and Spanish inhabitants of the place remained 
unaffected. There were strangers there, however, and among the rest seve- 
ral families from Natchez, who passed through New Orleans on their way 
thither, and they suffered. Dr. Bell,* in speaking of yellow fever at that 
place, apparently in the same year, says, it prevailed a with such dreadful 
malignity as to prove fatal after a few days' illness, to several natives of the 
place/' The cantonmeut of the troops was two and a half miles southwest 
of the village of Shieldsborough. 

The late Judge Butler, of the neighborhood of St. Francisville, gave me 
the following account of this epidemic. 

On the 29th of July, 1819, there was a violent hurricane, which rolled 
up the waters of Lake Borgne upon the land, and spread over it an immense 
quantity of sea-weed. The village at Pass Christian, four miles from Shields- 
borough, across the bay, was nearly destroyed by it, and many of the inha- 
bitants sought an asylum in Shieldsborough. The yellow fever prevailed 
that year in New Orleans, and as usual a number of persons fled to Shields- 
borough, where they were taken down with the disease, but it did not extend 
to others. The next year, 1820, the coasts around the bay were foul, from 
the exuviae thrown upon them, by the hurricane the year before, and the 
fever prevailed violently among the resident inhabitants. Dr. Merrill, how- 
ever, says that in his investigation of the remote cause of the fever that 
season, he found the sea-weed perfectly dry and emitting no smell whatever. 
The drought was, in fact, very great that summer and autumn. 

It appears, then, on the whole, that persons who had not been in New 
Orleans were affected ; but, whether from a cause originating on the shores 
of the bay, or whether the disease was introduced from the city, remains 
undecided. 

2. Season of 1829. — This is the next year in which I have found any 
account of yellow fever at this place. As already mentioned, the troops 
usually stationed at Fort Wood, were this summer transferred to Shields- 
borough, where the fever, which was at the time epidemic in New Orleans, 
soon appeared among them. 

According to Surgeon Lining, it commenced on the 5th of August, and 
by the end of the month, all the officers and men present — with the excep- 
tion of four privates — were attacked. f Dr. Dalton, who was stationed at 

* Army Register, p. 20. t Stat. Rep. U. S. A , p. 278. 



INTERIOR VALLEY OF NORTH AMERICA. 215 

Fort Pike, was ordered to Shieldsborough to assist Dr. Lining. He has 
informed me that a few of the inhabitants and visitors had the fever. Re- 
moving to Fort Pike he was seized with it, but no other case occurred at 
that post. 

3. Season or 1839. — According to Dr. Monette,* a number of those 
who had fled from New Orleans were taken down with the fever, but it did 
not extend to the resident population. 

II. Bay op Biloxi. — It has been already stated that the first French 
settlement on the coast of the Gulf of Mexico, was at this bay. Three 
years after it was made, that is, in 1702, it was assailed by what was re- 
garded as yellow fever. f This was the first occurrence of that disease 
north of Havana. The settlement did not flourish, and we hear no more of 
the fever at this place till it is mentioned as occurring among, or intro- 
duced by those who left New Orleans to escape from it. From its position 
it has daily intercourse with both that city and Mobile ; yet both Prof. Car- 
penter and Dr. Monette (believers in transmission) are limited to a single 
invasion, that of 1839 ) a season in which a larger number of places were 
affected than in any other, as may be seen by the general table. Down to 
that year, as Dr. Monette was informed by G. L. C. Davis, Esq., of New 
Orleans, refugees from the city were often attacked with the fever at Biloxi, 
but the resident inhabitants escaped. But in 1839, after seven persons had 
sickened in Belman's Hotel, near the steamboat landing, several citizens of 
the place contracted the disease. J It is to be regretted that we are not 
told, whether the seven were refugees from New Orleans or Mobile ; and 
also, whether those who are said to have suffered from visiting the hotel had 
or had not been in one of those cities, after the fever began to prevail. 

III. Pascagoula Bay. — Like the other bays just mentioned, this has 
been one of the places of retreat for the people of New Orleans and Mobile, 
especially the latter, during epidemic invasions of yellow fever ; but neither 
Dr. Monette, Prof. Carpenter, nor any other historian, has mentioned its 
occurring there. I have been assured, however, by Dr. Fearn, of Mobile, 
that in 1839, when Biloxi was affected, the settlements around Pascagoula 
Bay likewise suffered. He was there, and assured himself that inhabitants 
of the place, who had not during the summer visited any place where the 
fever was prevailing, were affected with it. 

IV. Observations of a Gulf Commander. — This seems to be a proper 
place to introduce the observations of the commander of one of the steam- 
packets on which I sailed between New Orleans and Mobile. Capt. Hutchins, 
had been an intelligent and observing navigator of the Gulf for fifteen years. 
Yellow fever in his opinion is essentially a city disease. He is not pre- 
pared to believe it contagious. In 1839, when it prevailed violently in the 
two cities just mentioned, he was piloting a steamboat running between 

* Observations, p. 117. 

f Bancroft's Hist. Col. U. S., vol. iii. ch. xxi. Lewis, in New Orleans Jour., vol. i. No. 4. 

t Observations, p. 117. 



216 THE PRINCIPAL DISEASES OF THE 

them. When the boat reached Milneburg, the terminus of the New Orleans 
and Lake Pontchartrain Railroad, he and the clerk of the boat were accus- 
tomed to visit the city, and at length both were seized with the fever ; but 
the other officers and sailors remained healthy. 



SECTION IV. 



BAY AND CITY OF MOBILE. 



I. Season of 1705. — For the topography of this locality the reader is 
referred to Plate V. Sect. VIII. Ch. III. Pt. I. Bk. I. Two or three years 
after the settlement of Mobile, then called Fort Louis, it suffered, as Dr. 
Lewis* believes, from yellow fever; He refers to Bancroft's History of the 
Colonization of the United States ; but I have not been able to find any 
mention of it by that historian. If, however, it prevailed at Biloxi in 1702, 
it may be presumed to have occurred in Mobile in 1705. 

II. Season of 1765. — We read no more of the fever for sixty years, 
when its historian is Romans, ■(" who informs us that the fever prevailed in 
that year as a severe epidemic. After mentioning the dissipated habits of 
the people, their drinking stagnant water, and the position of the town 
opposite the marshes of the bay, he adds, " In the year 1765, a regiment of 
[British] troops arrived from Jamaica, and brought with them a contagious 
distemper/' In a subsequent part of his book, page 232, he indicates that 
this distemper was the fever we are now considering. "I am persuaded," 
says he, " that whenever the yellow fever has made its appearance in the 
Floridas [which at that time included Mobile], it was imported from Jamaica 
or Havana, as was the case in 1765, which, by the way, was almost 
universally an unhealthy era, as well in Europe as elsewhere." The popu- 
lation of Mobile at this time consisted only of a few hundred French and 
Spaniards. 

III. Seasons from 1765 to 1819. — I can find no evidence of the oc- 
currence of the fever through a period of fifty-three years from the first of 
these dates j though during that period it was epidemic in New Orleans 
seven times. 

Mr. Krebs, a veritable Creole, who was in Mobile in the year 1811, says, 
that a man attached to a vessel from Pensacola, where it prevailed, was 
seized with it in Mobile, and died'; but no other person had the disease. 
Judge Chamberlain, who arrived in 1813, informed me, that the public 
opinion then was that Mobile was exempt from the fever. The people of 
New Orleans were accustomed to escape from that city, to this, when the 
disease prevailed there. When Judge C. arrived, the population of Mobile 
did not exceed 500, — chiefly French, a few Spaniards and Anglo-Americans. 

* New Orleans Med. Jour. vol. i. No. 4. 

t A Concise History of East and West Florida, by Capt. Bernard Romans, Phila. 1776, p. 13. 



INTERIOR VALLEY OF NORTH AMERICA. 217 

The place had no foreign commerce, and but two or three schooners plied 
between it and New Orleans. From the year of his arrival (1813) to 1819, 
no yellow fever occurred. Dr. Levert, who settled in this city about the 
year 1830, informs me, that the most careful inquiry had not enabled him 
to* find any account of the prevalence of the fever from 1765 to 1819. 
Between these two dates there was a considerable immigration of Americans, 
who began to build wharves, and the number of vessels coming into port 
multiplied. In the years 1818 and 1819, there was much immigration. 

IV. Season of 1819. — Judge Chamberlain remembers that the month 
of July, and the early part of August, were remarkable for the quantity of 
rain. It fell almost daily, for nearly forty days, with occasional strong 
winds, approaching to hurricanes, and producing high tides, which threw up 
drift-wood and filth on the quay, not then raised to its present height, while 
the water passed under a great many houses. 

Early in August, a small vessel arrived from the West Indies and came up 
to the wharf. Two days afterwards a young man of Mobile, who had come 
as a passenger, left her, sickened with yellow fever, and died at the corner 
of Water and Dauphin Streets. Another died on board the vessel about the 
same time. These were the first cases, Mr. Krebs confirming the state- 
ment of Judge Chamberlain. The fever soon spread over the village, which 
was chiefly east of Dauphin Street. The population at this time was 12 or 
1300, about one-third of whom were French and Spaniards. They suf- 
fered much less than the Americans and Irish. According to Dr. Lewis, 
about 300 of the inhabitants fled on the appearance of the fever. The mor- 
tality was very great. The type of the disease was the worst he ever saw. 
Persons were often found dead in the streets in the morning. It continued 
till severe frosts occurred in November. Many persons who escaped to the 
country returned too early and were attacked. As well as he recollects, the 
summers between 1813 and 1819 were not like that of the latter year. To 
this circumstantial account I may add from Dr. Lewis,* that from the best 
accounts he has been able to procure, the filling up of that portion of the 
town which now composes the commercial part of the city, was commenced 
early in the spring of 1819, and the materials were sand and marsh mud, 
abounding in vegetable matter. As that margin of the city was itself a 
marsh, long wooden wharves were projected over it to the deeper water. 
The houses were built on wooden pens to raise them above the high tides. 
The rains began on the 24th of June ; and a great hurricane, mentioned by 
Judge Chamberlain, occurred on the 29th of July, inundating all the lower 
part of the town, and depositing vast quantities of sea-weed and other exu- 
viae upon it. The months of April, May, and June, had been unusually 
warm. The hurricane was followed by cool nights. Thus far the recol- 
lections of Judge Chamberlain; and the combined recollections of that 

* New Orleans Med. Jour. vol. i. p. 284. 



218 THE PRINCIPAL DISEASES OF THE 

gentleman and other old citizens, as given by Dr. Lewis, corroborate each 
other, but what follows in relation to the advent of the fever differs from 
the reminiscences of the Judge and Mr. Krebs. 

" Intermittent and remittent fever, in a very mild form, began to prevail 
early in May. In June, there were several deaths of bilious fever ; they 
increased in number and severity during the month of July ; and by the 
6th of August, there were some thirty deaths of this disease. I have the 
authority of several gentlemen, among them our late esteemed mayor, Mr. 
Hall, for stating that one case of black vomit occurred in the latter part of 
May. In relation to the number of cases which occurred in June, there are 
various estimates; I am not satisfied that more than two or three occurred. 
In July, there were some few sporadic cases, as they were called, probably 
six or eight \ and all agree that in the first week of August, the yellow fever 
became predominant among the whites. The first victims were some me- 
chanics, seven in number, who had lately arrived, and resided in a wooden 
tavern on Dauphin Street. They were attacked about the same time, and 
died within a few hours of each other, all having black vomit. From this 
time until winter, the scene was truly lamentable. So concentrated was the 
poison, and so great its facility in adapting its deadly effects to different 
constitutions, that no one could escape. The mulatto, the black, the Indian, 
and the white,the native and stranger, were alike its victims. 

" It was attempted by the violent partisan contagionists of New York, 
through agents here, to induce the impression that the disease was of foreign 
origin. When this became a question, the citizens held a meeting, and ap- 
pointed a committee of seven of the most intelligent of their body, to report 
upon the causes of the disease. This committee unanimously reported in 
favor of its domestic origin, and referred to the causes which I have briefly 
alluded to, as the agents of its production. Several small water-craft 
arrived here during the summer. The one which it was ingeniously sup- 
posed brought the infection, came into port about the middle of July, from 
Havana. The citizens were, however, not only sensible of unusual sick- 
ness, but knew there were cases of black vomit, before the arrival of the 
suspected vessel. They made this report in accordance with these facts. 

/'The whole number of deaths was 430. This mortality, in a population 
not exceeding one thousand, and more than one-half of them exempt, under 
ordinary circumstances, from either bilious or yellow fever, is probably 
without a parallel on this side of the Atlantic. From a mutilated list of 
interments for September, I get the names of eighty who died. Twelve of 
these are slaves, twenty-five free colored or quadroons, and forty-three of 
the names are those common to Americans, English, and Irish. By the 1st 
of October such of the whites as remained alive, fled the city ; in that 
month, the deaths were mostly from the mixed Creoles of the place. I 
believe, from all the information I can obtain, the deaths were equally 
divided among the two classes of people/' 



INTERIOR VALLEY OF NORTH AMERICA. 219 

Neither Dr. Monette nor Prof. Carpenter refers to this epidemic. It is 
worthy of remark that a case of black vomit is said to have occurred in 
each city in the month of May ; after which there were scattering cases in 
both cities, till the first week of August, when the fever became epidemic in 
both. 

V. Seasons of 1820 to 1824. — The year 1820 seems to have been 
exempt; while the number of admissions into the Charity Hospital at New 
Orleans was 122, within nineteen of what it was the preceding year; but 
in 1821, when New Orleans had none, seven cases occurred in Mobile in the 
month of October !* Dr. Levert and Dr. M'Nelly have told me that from 
inquiry they have satisfied themselves that the fever really did occur spo- 
radically that year. In 1822, there were only four or five cases, though"!* it 
was epidemic in New Orleans. Judge Chamberlain recollects that there 
were a few. In 1823, there seems to have been none, and none or next to 
none in New Orleans, while it was fatally epidemic at Natchez, 300 miles in 
the interior. In 1824, six fatal cases in the month of September. J 

VI. Season of 1825. — After a five years' exemption from an epidemic, 
the city was this year reinvaded. Judge Chamberlain says it commenced 
down Water Street, in September, and lasted only about thirty days, being 
succeeded by bilious fever ; was less malignant than in 1819. Heard no 
allegation of its being imported j recollects no arrival of a vessel said to have 
yellow fever on board ; the commerce of the city had increased rapidly ; 
remembers nothing peculiar in the season. Dr. Lewis§ says it was preceded, 
in August, by what the Board of Health calls bilious fever, in many instances 
stated. September 2d, a case of yellow fever reported* 5th, three cases; 
8th, four cases; 11th, epidemic. No mention of the arrival of ships hav- 
ing the disease among their crews. Deaths of the autumn 120, many of 
which were from what was called bilious fever. Drs. Levert, M'Nelly, and 
Lopez, from subsequent inquiry, informed me that the disease was decidedly 
epidemic ; in New Orleans it was only sporadic. 

VII. Seasons of 1826, '7, and '8. — The gentlemen just named have 
from inquiry come to the conclusion that while the first and the last of 
these years were exempt, the autumn of 1827 experienced a considerable 
visitation, and Judge Chamberlain states the same thing. It commenced 
in August, down Water Street, where ships were repaired. Was at first 
fatal, but soon became manageable, and did not continue long. Many of 
the unacclimated had now adopted the practice of spending the summer 
and autumn in the country. The gentlemen just quoted says that Mrs. 
Warren died of yellow fever at Springfield this year, without having been 
in the citv. He thinks that country cases have generally been contracted 
in town. Knows of no instance of its propagation in the country. There 
was a hurricane about the end of June, which drove the vessels up to Water 
Street. Dr. Lewis says that during these three years, the population had 

* Lewis, p. 286. f Ibid. J Ibid., p. 287. § Ibid., p. 288. 



220 THE PRINCIPAL DISEASES OF THE 

increased by immigrants from the northern part of the United States and 
from Ireland. The fever was epidemic this year in New Orleans. Prof. 
Carpenter makes no mention of either visitation. 

VIII. Season of 1829. — The disease, according to the facts collected by 
Drs. Levert, Lopez, and M'Nelly, was epidemic this autumn. Dr. Lewis 
informs us that the deaths from bilious and yellow fever amounted to about 
130. The first case of the latter was published by the Board of Health on 
the 14th of September, and on the 22d it was pronounced epidemic. This 
year it was epidemic in New Orleans, beginning in May, and continuing 
to occur in June. This epidemic was not mentioned by Dr. C. 

IX. Seasons of 1830, '31, '32, '33, '34, '35, and '36.— According to the 
recollections of Judge Chamberlain, and the testimony of the physicians 
of the city generally, many of whom arrived there within the years just 
enumerated, they were free from the fever. Two summers were attended 
with great rains, storms, and other atmospheric phenomena, which raised in 
the minds of many persons anticipations of the fever; but it did not appear. 
During this period it was three times epidemic in New Orleans; once exten- 
sively sporadic, twice moderately so, &c, and once only three cases were 
sent to the Charity Hospital. In these years the population of the city 
nearly trebled, and its commerce increased in a still higher ratio.* Judge 
Chamberlain informed me that the ground south of Royal Street and the 
river was raised by filling up ; and the streets were graded and covered 
with sea-shells this summer. 

X. Season of 1837. — We come to a period when most of the present 
physicians of Mobile were in the city, and consequently more can be known 
of this and the subsequent invasions, than of the earlier. Dr. Lewisf 
informs us, that the number of deaths from yellow fever was 350, conse- 
quently this was a fatal epidemic. I have no reliable account of the 
weather which preceded this invasion. Judge Chamberlain thinks the sum- 
mer was unusually hot. Dr. Nott says the weather had been dry, and that 
a northerly wind preceded the outbreak. The usual visitation of autumnal 
fever began with the warm weather and increased with its progress. Dr. 
Nott informed me that on the 20th of September, four cases of the 
fever occurred on the same day. One at the corner of Royal and St. Fran- 
cis Streets, two in St. Francis near Clabourne Street, and one in Ann 
Street near the forks of the road to Spring Hill. There was none in the 
ships, lying either at the wharf or in the harbor near the mouth of the 
bay. No other cases occurred for three weeks, when it broke out all over 
the city, affecting great numbers. Immediately before this second invasion, 
there was a southern storm, which threw the waters of the bay over the 
island marshes in front of the city, and upon the quay, even to the houses 
on Front Street. Dr. LewisJ confirms the statement, that on the 20th of 
September, four cases occurred about the middle of the city. On the 2d 

* Lewis, p. 287. t Ibid. $ Ibid. 



INTERIOR VALLEY OF NORTH AMERICA. 221 

of October, lie adds, the wind changed, and a very tight frost appeared, 
when many of the absentees returned to the city, and on the 10th, " the 
fever made its appearance in every section of the town '" and continued 
to prevail till the middle of November. Dr. Huestis recorded at the time, 
that it was much more fatal to those who had recently immigrated from the 
North than to those who had come from the same region four or five 
years before, although no yellow fever had occurred within that period. 
This year more persons perished from the fever in New Orleans than had 
ever died before in one autumn. It began on the 24th of July, eight weeks 
before its first appearance in Mobile, and nearly eleven weeks before its second 
or epidemic outbreak. Neither Dr. Monette nor Prof. Carpenter refers to 
this invasion. 

The following year, 1838, was nearly exempt from the disease ; Drs. 
Levert and M'Nelly saw a few cases ; a great number of Irish and German 
laborers arrived in the city this year. 

XI. Season of 1839. — Greatly epidemic. Judge Chamberlain does not 
recollect any peculiarity of the season. Dr. Nott says the wind was south- 
erly, with four or five showers a week, for six weeks before the disease set 
in, but such weather is not uncommon in summer. For several days before 
the first case occurred the weather was dry, with northerly wind, an atmo- 
spheric condition which continued with but little variation for nearly a month. 
The first case, says Dr. Lewis,* occurred on the 11th of August, and in ten 
days it became general throughout the entire city. So predominant was its 
influence that no other disease was to be seen, but many cases were mild. # Dr. 
Lewis does not mention the locality of the first patients, but Dr. Nott says 
it was at the corner of Government and Hamilton Streets; and that the 
fever spread from that point, as from a focus \ affecting not only the whole 
city, but its environs and the country, to the distance of two or three miles 
from the bay. This account of its spread among the people in the neigh- 
borhood of the city was verified by Dr. Fearn and Dr. Levert. The water- 
men of the lighters of the bay, Dr. Nott says, were affected, but not till 
after it had appeared in the city. He does not know whether it prevailed 
in the shipping at Mobile Point, and Dr. Lewis is silent on that subject. 
Everybody assured me, that there was no allegation that it was imported. 

It should be borne in mind that this was the epidemic which prevailed 
over a greater geographical extent than any other which has ever visited 
the basin of the Mississippi. The first case sent to the Charity Hospital 
in New Orleans was on the 23d of July. Its greatest prevalence in that 
city was in August, which seems to have been the case in Mobile. 

Dr. Levert, who escaped the fever in 1837, had it this year. Indeed, all 
the physicians of the city except two were ill. The Doctor saw three or 
four second attacks in persons who had not been away from the place. 
Saw one patient in a third attack. Saw a second attack seven weeks after 

* Lewis, p. 289. 



222 THE PRINCIPAL DISEASES, OF THE 

the first. Many immigrants who escaped the fever in 1837 were now 
affected. The mortality was chiefly among the poorer immigrants, many 
of whom died without medical aid, while the physicians of the city were 
sick. 

On the 7th of October, when, as I am informed by Dr. Gates, the epi- 
demic had greatly abated, a fire broke out, and in a few hours consumed 
twelve squares. It was not followed by any revival of the fever ; which, 
however, continued to affect individuals returning to the city till Decem- 
ber. Dr. Crawford saw a young man with the disease long after white 
frost had occurred, who had just come to the city for the first time. Late 
in this month a man came to the city, and lodged in a house where several 
persons had died ; he contracted the disease. However, according to Dr. 
Nott, in about six weeks from the 11th of August, it had begun to abate, 
and was almost entirely arrested by some severe frosts which occurred near 
the end of October. 

XII. Seasons of 1840, '41, and '42.— A. D. 1840. This year was un- 
usually free from all kinds of disease. No yellow fever occurred. New 
Orleans was equally, or almost equally, exempt, as but two cases were sent 
to the Charity Hospital. 

A. D. 1841. The salubrity of this year was almost equal to the last, but 
there were, according to Dr. Lewis,* and Drs. Levert, M'Nelly, and Lopez, 
a few cases of yellow fever in persons from the country. In New Orleans, 
however, it prevailed to such an extent, that a greater number of patients 
were sent to the Charity Hospital in September, than were ever before taken 
there in a single month. 

A. D. 1842. This year the fever was mildly epidemic. The number of 
cases, according to Dr. Lewis, did not exceed 160, and 70 deaths. In a joint 
conversation with Drs. Fearn, Levert, Crawford, Ross, Lopez, Nott, and 
M'Nelly, the following account of the first cases of this epidemic was made 
out. First case, about the 18th or 20th of August, at the corner of Govern- 
ment and Hamilton Streets. Second, corner of Maiden Lane and Water Street, 
fatal. Third, fifty yards from the second, on the 29th of August, fatal. 
Fourth, on the same day, corner of Spanish Alley and Church Street, in the 
midst of dirt and filth. Fifth, in Dauphin Street, between Laurence and 
Hamilton, fatal. Sixth, on Franklin Street between Government and Conti, 
fatal. Subsequently, for three or four weeks, cases continued to occur, chiefly 
south of Dauphin Street, and off to the west. Afterwards it crossed 
Dauphin Street, but finally, the cases south of that street, were eight or 
ten times more numerous than north of it. Dr. Lewis says that it was 
confined to the southern section of the city. No case originated north 
of Dauphin Street, which runs east and west, dividing the city into two 
equal halves. There were cases at the Pavilion, three miles down the bay, 
but all the patients had been in the city. 

* Lewis, p. 289. 



INTERIOR VALLEY OF NORTH AMERICA. 223 

There was no suggestion of importation. The disease was moderately 
epidemic in New Orleans this year. Prof. Carpenter has not referred to its 
occurrence in Mobile. 

XIII. Season of 1843. — The epidemic visitation of this year was vio- 
lent and fatal, but fell chiefly on that part of the city north of Dauphin 
Street, which had escaped the year before. When it commenced, the 
autumnal fever had been rife for several weeks. By collating the ac- 
counts of the highly respectable body of physicians named in the preceding 
article, I am enabled to state, on the authority of Dr. Crawford, that the 
first unequivocal cases were on the 18th of August,* one of which proved 
fatal. The case of recovery was on Conception Street, between Conti and 
Dauphin, the other at the corner of St. Anthony and Hamilton Streets. 
On the 24th, a case, which ended favorably, on the corner of Church and 
Water Streets; and another (Dr. Lewis, p. 290), which proved mortal. 
On the 26th, accordingto the same authority, another, fatal. The localities 
of these two not given. On the 3d of September, Dr. Fearn had a case, 
near the corner of Dauphin and Royal Streets, restored. These were nearly 
all the well-marked cases that occurred, till after the end of the first week 
of September. On the 10th and 12th, Dr. M'Nelly had three cases near 
the corner of Hamilton and St. Anthony Streets ; on the 12th, Dr. Levert 
had one at the same intersection ; on the 13th, Dr. Fearn had one on the 
corner of Francis and Cedar Streets ; on the 14th, Dr. Levert had one on 
the corner of Royal and Conti Streets. Between the 13th and 19th, Dr. 
Crawford had, or saw, four cases in one house near the corner of Hamilton 
and St. Louis Streets, three of which proved fatal. These patients had 
-just returned from a trip of pleasure and dissipation to the opposite side of 
Mobile Bay, here twelve miles wide, where they spent two or three days 
and nights. On the voyage they were becalmed, and for some time exposed 
to the burning sun. About five others were of the same party, of whom 
four died with the fever not long afterwards. In the same neighborhood, 
at about the same date, Dr. Crawford had five cases in one family and nine 
in another. On the 15th, 16th, 17th, and 21st, Dr. Fearn had cases at the 
corner of Commerce and St. Anthony, of Franklin and Monro, in Royal, 
between Conti and Dauphin, and at the corner of Joachim and Dauphin 
Streets; on the 16th and 18th, Dr. Levert had three cases — one, corner of 
Dauphin and Hamilton — one on St. Louis below Franklin, and one on the 
corner of St. Michael and Jaques Street. After the 20th, the fever began 
to assume an epidemic character (Levert), and by the 6th of October, it 
had, according to Dr. Lewis, extended to all parts of the city. The reader 
will observe in this narrative a perpetual recurrence to the same streets ; 
and by turning to the map will at once see the part of the city in which 
the disease made its appearance, and where it prevailed for three weeks ; 
after which, in the language of Dr. Lewis, it could be traced in a south- 

* Dr. Lewis, p. 291, says the 24th. The discrepancy involves nothing of importance. 



224 THE PRINCIPAL DISEASES OF THE 

easterly direction until it reached the heart of the city. While it was here 
exerting its deadly influence, it appeared in a block of buildings some 
distance from the other localities, and westwardly from the bay. While 
the yellow fever thus prevailed, other parts of the city, in which it had not 
yet occurred, were infested with ordinary intermittents and remittents. 
The yellow fever was confined very much to the better class of citizens, for 
after 1839, the immigration of laborers had been nearly suspended, and 
negroes were more employed in the city than formerly. The epidemic 
continued till about the 5th of November. The number of cases was esti- 
mated at 750; the population of the city being at the time (including those 
who fled to the country), 14,000.* 

Dr. Nott sent some citizens to Spring Hill, after the first cases occurred 
They remained exempt, but returning to the city in November were attacked. 
He knew several instances of persons sojourning there for the summer, 
who from spending a day in the city were attacked. In two instances 
it was a fortnight after the visit before the disease was developed. In no 
case did the disease spread from those who had contracted it in the city, 
nor is it known to have originated there. Of one large family three of the 
members visited the city, and all had the disease ; eight or ten others re- 
mained out, and all escaped it. Two young men came in and spent only an 
hour each, yet both were attacked with the fever. 

Dr. M'Nelly knew of a young man from the Atlantic States who spent 
two hours in the city, then passed on to Spring Hill, and in a few days after 
sickened of the fever and died. A patient of the same gentleman, the 
mother of a family, died of the fever ; the survivors moved to a house low 
down on Water Street, where they were attacked, and two men who lived 
there also suffered attacks. As early as June, a young man retired from 
the city to Spring Hill; some time afterwards he returned on a visit. 
Twenty days after this he was seized with intermittent fever, which con- 
tinued for a week, when he died with black vomit. 

On the 8th of December, this year, Dr. Levert had three cases of the 
fever. The cold which merely produces white frost will not finally check 
the disease. The temperature of the ground need not fall below 40° for 
this effect to be produced. To terminate an epidemic, ice must form on the 
surface of the ground. — (Dr. Fearn.) 

The outbreak of the fever this year was remote from the wharves and 
shipping, and no suspicion was entertained by anybody of its introduction 
from abroad. As to local causes, none could be assigned, unless a conside- 
rable extent of excavation on the streets of that part of the city should be 
regarded as such. 

XIV. Season of 1844, '45, and '46. — Mildly epidemicf in the first, 
absent or slightly sporadic in the latter. I have seen no notice of the 
occurrence of the fever in the last year. 

* Lewis, p. 291. t New Orleans Journal. 



INTERIOR VALLEY OF NORTH AMERICA. 225 

XV. Season of 1847. — Epidemic. 

XVI. Season of 1848.— [MSS. wanting.— Ed.] 

XVII. Season of 1849.— [MSS. wanting.— Ed.] 

THE FEVER AT BLAKELY. 

I have not given the topography of Blakely in Book L, for it is to be 
classed with the towns that were, rather than those which now exist. It 
was commenced in the year 1815,* and a rapid emigration for several years 
raised it into a rivalry with Mobile, from which it soon fell off, and the 
voyager now scarcely recognizes it as even an inconsiderable village. Its 
site is the margin of the high tertiary plain of red clay and sand, which 
constitutes the eastern bank of Mobile Bay, near the junction of the Ten- 
saw Channel with the head of the Bay. Its distance is about twelve miles 
from Mobile, on the opposite side, and a little higher up the Bay. It had 
not an old Creole population, like Mobile ; but was essentially a new and 
suddenly-developed American town, composed largely of adventurers from 
the higher latitudes of the Western and the Atlantic States. 

It does not appear that the epidemic which visited Mobile, in 1819, af- 
fected Blakely ; but in 1822, when the fever was but lightly sporadic in 
the city, it proved a violent epidemic in Blakely.f Of the circumstances of 
its origin there nothing I believe is now known. Soon after this date the 
immigration to Blakely ceased, and was succeeded by the removal of many 
of its inhabitants. Since that year it has not, as far as I can learn, experi- 
enced a visitation; although Mobile, as we have just seen, has been several 
times invaded. 



SECTION V. 

PENSACOLA BAY. 

I. Under this head we may include the town of Pensacola, the Navy Yard, 
nine miles below, the Naval Hospital, a mile further down, and the three 
forts, — Barrancas, a mile below the Hospital, and Fort M'Cree and Fort 
Pickens, a mile lower and at the very entrance of the Bay. All these places 
and establishments are on the right or western side of the Bay, except Fort 
Pickens, which is on the end of St. Rosa Island. 

II. The first settlement on Pensacola Bay was made by the Spaniards, in 
1696, near the mouth of the Bay. In 1719, the French took possession of 
this and other settlements made near it. The Spaniards, however, retook it 
in less than two months ; but the French regained it within a year, and kept 
possession of it till 1722, when it was restored to Spain. In 1754, the set- 
tlements were concentrated on the present site of Pensacola. In 1763 it 
was ceded to England, and in 1765 the town was laid off with regularity. 

* Darby's Emigrant's Guide, p. 36. f Judge Chamberlain— Dr. Lewis. 

VOL. II. 15 



226 THE PRINCIPAL DISEASES OP THE 

In 1781, it was captured by the Spaniards, who thenceforward retained pos- 
session of it till Florida was ceded to the United States, in 1821. In this 
way, while the parent-stock of its population was Spanish, many French and 
English were engrafted upon it. After the cession to England, in 1763, 
many of the Spaniards left it for Cuba, and Englishmen supplied their places. 

After the capture of 1781, nearly all the English left it; and Spaniards 
with a few French came in. After the cession to the United States, a large 
part of the Spanish population again departed for the Havana; and a much 
greater number of Americans, with a considerable portion of our army, 
supplied their places. The latter were garrisoned at Cantonment Clinch, 
two miles west of the town, on a pine plateau. 

From the discovery of Pensacola Bay down to the present time, it has 
been the principal harbor of the ships of war which the nations pos- 
sessing it have had cruising in the Gulf of Mexico ; but the commerce of 
the town has never been considerable. Schooners have at all times, and 
especially since 1821, kept up a regular intercourse with New Orleans and 
Mobile ; and, now and then an arrival from Havana, more rarely from 
Vera Cruz and other ports of the Gulf of Mexico and Caribbean Sea, has 
presented a trading vessel in the midst of the naval marine. Let us now 
proceed to inquire into the invasions of yellow fever, as experienced by the 
town, the naval and military establishments, and the shipping. 

III. Season op 1765. — I have met with no record or tradition of yellow 
fever on Pensacola Bay earlier than 1765, two years after it was ceded to 
the English. On the events of that year Lind has the following para- 
graph : — * 

" At Pensacola, where the soil is sandy, and quite barren, the English, 
have suffered much by sickness; some, for want of vegetables, died of scurvy; 
but a far greater part of fever. The excessive heat of the weather has 
sometimes produced in this place a severe fever, similar to that which in the 
West Indies goes under the name of yellow fever. This, in the year 1765, 
proved very fatal to a regiment of soldiers sent from England, unseasoned 
to such climates, from the unfortunate circumstance of their being landed 
there in the height of the sickly season. It raged chiefly in the fort, where 
the air in the soldiers' barracks, being sheltered from the sea-breeze by the 
walls of the fort, was extremely sultry and unhealthy. And it is worthy of 
remark that during the fatal rage of this fever at Pensacola, such as lived 
on board the ships in the harbor escaped it." 

Bernard Romans, t a distinct authority, refers to the same epidemic. 
Thus we find that the first appearance of the fever was among newly-arrived 
immigrants from Europe. It is worthy of remark, that in 1781 and '82, when 
the English were expelled, and the Spaniards returned from Cuba and Spain, 
no yellow fever appeared. 

* Essay on the Diseases incident to Europeans in Hot Climates. Am. Ed. p. 25. 

f Concise History of East and West Florida. J Jno. Innerarity, Esq. 



INTERIOR VALLEY OF NORTH AMERICA. 227 

IV. Season or 1811. — From 1765 to this date, a period of forty-seven 
years, no yellow fever appears to have occurred. The commerce of the place 
was small; but, being a Spanish town, we may presume most of its trade 
was with the Havana. In the summer of 1811, many long ditches were dug- 
through the semicircular swamp which invests the town in its rear ; and 
soon afterwards, there occurred a dry north wind, so cold as to render fires 
comfortable. The fever then broke out, and was fatal to nearly all the 
Anglo-American population ; affecting in a milder way many of the Spa- 
niards.* In this year, the fever was epidemic in New Orleans. Eleven years 
passed away without another invasion. The habits of the Spanish people 
were simple and temperate ; they ate but little meat, refrained from ardent 
spirits, and drank weak wines. f 

Y. Season of 1822. — In 1821, General Jackson, with a considerable body 
of troops, was ordered to take possession of Pensacola, Florida having been 
purchased from Spain. At the same time, there was a rush of emigrants 
to that place from various parts of the United States. This influx began in 
July, and continued throughout the following autumn and winter. The 
houses were so crowded that many persons slept in the porches and verandahs 
all night,J but they continued healthy. No yellow fever appeared, either in 
the town, the camp, or the marine. 

Before the ensuing summer, 1822, a considerable number had left the 
place, but it was still thronged with strangers. Meanwhile, the Spanish 
troops, and all the officers and agents of that government, with a portion of 
the Spanish people, had departed for Cuba.§ The new-comers indulged 
freely in meat and whiskey. || More ditching of the swamp was now per- 
formed. ^f The mean summer heat of that year at Camp Clinch, two miles in 
the country, was 82-71°, which is less than half a degree above the mean 
summer temperature of the post, as deduced from seven years' observations. 
The number of rainy days was forty-two, or six more than the summer mean 
of the same period.** Thus there was no remarkable deviation from the 
ordinary course of that season ; yet Dr. Brosnaham and Mr. Innerarity 
recollect, that the summer was dry, and the springs around the town, which 
are supplied by the rains which fall on the adjacent sandy plain, were very 
much reduced in volume. It would seem, then, that the rains were not copious. 

Although, as we have just seen, the mean heat of the summer was not 
above the standard temperature of Pensacola, that of June was greater than 
that of July by 2-29°, and above that of any other June during the seven 
years that observations were made at Camp Clinch; and although the summer, 
taken altogether, was not particularly wet, July was, having twenty rainy 
days,ff during which a storm from the southwest, of several days' duration, 
occurred. JJ 

* Jno. Innerarity, Esq. t Dr. Brosnaham. % Mr. Areus. 

§ Mr. Carro. || Dr. Brosnaham. f Mr. Innerarity. 

** Army Meteorological Register. ft Ibid - tt Medical Stat, of the United States Army, p. 36. 



228 THE PRINCIPAL DISEASES OF THE 

According to Assistant-Surgeon M'Mahon,* the first five months of the 
year were remarkably healthy. In the sixth (June), the inhabitants com- 
plained of lassitude, impaired appetite, and a depression of spirits. Towards 
its close, and in July, a number of severe cases of fever occurred, but none 
of them put on the aspect of yellow fever. There was, also, a fatal epidemic, 
the character of which was not observed, among dogs, foxes, and panthers, 
and many of the two latter were found dead in the woods. 

In the month of July, a vessel [the Alabama. — Ed.] laden with spoiled 
codfish, from the North, put into the port of Havana, where the smell of the 
fish was found to be so offensive, that the city police ordered her to sail to 
some other port, or to throw her cargo into the sea, outside of the bar. She 
chose the former, and departed for Pensacola, which place she reached within 
the same month. Coming up the bay to the town, she anchored at the end 
of the long wharf, where she lay for eight or ten days. She had no case of 
fever on board. 

After landing a few hundred-weight of fish, the vessel, by order of the 
police, attempted to sail out of the bay, but grounded near its mouth, in 
front of Fort Barrancas. She there discharged her cargo upon the beach, 
where it laid for a fortnight, when it was sold at auction. The captain and 
mate, and some of the sailors engaged in this duty, fell sick with yellow 
fever, and died ; but, according to Dr. Merrill,"}" the troops of Fort Barrancas 
about one hundred in number, although exposed daily, for a month, to the 
stench of this damaged cargo, lying near them on the beach, experienced no 
attack of yellow fever till three weeks after it was removed. 

Several persons in Pensacola purchased quantities of the fish, which they 
brought up to town. The police at length ordered the whole to be buried. 
The first cases of the fever, as Mr. Barkley informed me, occurred in the 
neighborhood of some of the fish thus brought back. J 

I think it remarkable, that Dr. Merrill and Dr. M'Mahon of the army, 
who have written on this epidemic, said nothing of this vessel ; and that I 
heard nothing of it, in conversing with many intelligent gentlemen of Pen- 
sacola, who were there at the time. 

According to Mr. Barkley, the first deaths from yellow fever were on the 
15th of August, after which no more occurred till the 25th; but Dr. 
M'Mahon (loc. cit.) informs us, that the first was on the 7th, in a lady re- 
cently arrived from New Orleans, who died with black vomit under 
the care of Drs. Elliot and Bronaugh, of the army. " About the same time/ 7 
he adds, " two other cases of malignant fever occurred in a quarter of the 
town which had been considered the most healthy. Both these patients/' 
he continues, "died with black vomit on the 12th, and on the 13th, the 
Board of Health publicly announced the epidemic, and advised all who 
could, to leave the town." Now we see, by this statement, that two deaths 

* Med. Stat, of the United States Army, p. 36. f PWL Jour. vol. ix. p. 238. J Mr. Barkley. 



INTERIOR VALLEY OF NORTH AMERICA. 229 

with black vomit had occurred in a part of the town considered the most 
healthy on the 12th, and that the Board of Health had publicly announced the 
fever on the loth; but, in the account Prof. Carpenter* has published, it is 
stated that the Alabama arrived about the middle of the month, and that a 
few days afterwards, the captain died on shore, of the fever. After his 
death, the lady at whose house he lodged, took the disease, and subsequently 
her daughter, lohen the boarders fled to different parts of the town, where 
most of them sickened, and nearly half died. It is impossible to read this 
narrative without feeling that the whole of it relates to events altogether 
posterior to the time when the two patients who died on the 12th were 
attacked ; and who, it may be presumed, sickened as far back at least as 
the 8 th or 9 th. It would appear, then, that the arrival of the Alabama was 
a mere coincidence, and not the cause of the epidemic. This, however, 
would not prove that the family in which the boarders lodged, did not con- 
tract the disease from the captain; but, certainly, diminishes its probability, 
as they might have had it from the state of the atmosphere, which seems to 
have been prevalent before the arrival of his vessel. 

Between the 13th and 20th, upwards of twenty deaths occurred. The 
disease now spread rapidly, and with a degree of malignity rarely equalled 
in the annals of this destructive malady. 

The troops were as yet stationed in town, but on the 26th, they were removed 
to Camp Clinch, in the pine woods, up to which time they remained healthy. 
Not a case of fever appeared to originate in the cantonment, but a large 
proportion of the party left for a longer period in town, to guard the unre- 
moved stores, fell victims to the disease. According to Dr. M'Mahon, 
neither age, sex, complexion, occupation, residence, nor birth, afforded ex- 
emption from the disease. Dr. Brosnaham, Mr. Barkley, and Mr. Areus, 
however, declare that the fever prevailed chiefly among the recent Anglo- 
Americans, and that but few Creoles were attacked. The greatest mortality 
was in September. Very few cases occurred after the 10th of October.f 
The whole number': of deaths was 257, J or about a fifth part of the popula- 
tion of the town. Of the army, Dr. Bronaugh and Dr. Elliot were its 
victims. Of the troops at Fort Barrancas, seven died.§ 

In regard to the origin of this epidemic, two questions may be asked. 1st. 
Did the schooner with spoiled fish, from the Havana, import the fever, or 
fomites, from which it might have sprung ? The answer must be in the 
negative, inasmuch as there was no case of it among her crew till after she 
had grounded near the mouth of the bay ; and they were occupied in land- 
ing the semi-putrid cargo on the beach ; a fact of which we have not only 
the declarations of all the people of Pensacola with whom I conversed, but 
the irresistible evidence that such was, at the time, believed to be her con- 
dition, from the fact that the people of the town went down, and purchased 

* Observations, p. 35. t Records of Town Council. 

J Mr. Barkley. § Med. Stat, of Army. 



230 THE PRINCIPAL DISEASES OF THE 

liberally of the fish. 2d. Was the cause of the fever developed by the de- 
composition of the fish. I do not see that this question can be answered. 
The fact that the captain and several sailors were attacked with the fever, 
and died while transferring the cargo to the shore from the stranded vessel, 
would seem to indicate this; but.it must be recollected, that they had been 
previously in the atmosphere of Havana, and had breathed that of Pensacola 
for ten days, where if the remote cause were afloat, they were, like the 
people of that town, acted upon by it. 3. Was the fever introduced from 
New Orleans by the lady who died before any other, on the 7th of August ? 
This does not seem probable — is scarcely possible — inasmuch as the first 
admission for that disease into the Charity Hospital, in that year, was on 
the 1st day of September, three weeks after her death. 

VI. Seasons of 1823, 4, 5, and 6, do not appear to have presented any 
case of the disease, though it was epidemic in two of those years, in 1824 
and 1825, in New Orleans ; and in one of them, 1825, in Mobile also. Prof. 
Carpenter, however, speaks of the disease as occurring in 1825, and is 
silent as to its prevalence two years afterwards. His reference doubtless 
was to the latter date. 

VII. Season of 1827. — I am indebted to Dr. Hulse, for many years 
the faithful, intelligent surgeon of the Naval Hospital, and to the official 
report of Dr. Lawson, now the active and efficient Surgeon-G-eneral of the 
Army,* for all I can say relative to the epidemic of this season. 

The mean heat of the summer, did not vary half a degree from that of 
seven summers, of which this was one ; but the temperature of July was 
the hottest which occurred during that period, and 1-8° above the mean 
of the whole. \ Several nights of cool damp weather preceded the outbreak 
of the disease.J 

Of the time and manner of the first cases, I know nothing. The troops 
were quartered at Camp Clinch, and none had the disease except Dr. Lawson, 
who was attacked eight days after his last visit to the town, and a sergeant, 
who contracted it by lodging there one night. Certain staff-officers and 
their families, who resided in town, experienced the disease ; and during 
their convalescence, were removed to the camp. The number of cases in 
Pensacola was not very great j and Dr. Lawson thinks the disease was on 
the whole less violent than that of 1822 j nevertheless some patients died 
on the first day of the disease. § As the epidemic of 1822 destroyed or 
drove away a large portion of the unacclimated, and as but few persons 
emigrated there afterward, the number liable to the fever was small. 

According to Dr. Hulse, the fever was epidemic in Pensacola. It 
also proved fatal to an old Spaniard, Col. Noriega, who had long resided a 
few miles higher up the Bay, on a bluff bank. Whether he had visited 
the town before his attack I cannot say. In the Navy Yard, nine miles 
below, three fatal cases occurred, and here again, I am unable to say whether 

* Medical Statistics of the TJ. S. Army, p. 58. t Army Meteor. Reg. % Med. Stat. p. 58. § Ibid. 



INTERIOR VALLEY OF NORTH AMERICA. 231 

the persons had been in town. The Naval Hospital had no case, and was 
so healthy, that the surgeon, Dr. Salter, went to Pensacola to assist in at- 
tending the sick, where he contracted the fever. 

At this time there were in the Bay, two of our national vessels, the 
Falmouth and Grampus, whose crews amounted to 250 men, and two Mexi- 
can ships of war were also there, but not a single case occurred on board any 
of them. The surgeon of one of the Mexican vessels visited Pensacola and 
went thence to Camp Clinch, where he sickened of the fever and died. 

The fever this year prevailed in a greater number of places around the 
Gulf of Mexico than it had ever done before ; and more patients were ad- 
mitted into the Charity Hospital than had entered it in any preceding 
season. 

VIII. Season of 1828-'33. — Through these six years the town of Pen- 
sacola appears to have been entirely exempt from the fever ; within that 
period, it was once epidemic in Mobile, and four times epidemic in New 
Orleans. Its last visitation of the latter city, in 1833, was the gravest 
which till then had been experienced. 

To what can we ascribe the continued immunity of Pensacola for six 
years ? It was not to the want of yellow fever in the Bay on which it 
stands, as appears from the following facts, for which I am indebted to Dr. 
Hulse. 

IX. Fever limited to Ships on the Gulf. — The Natchez. A.D. 1828. 
In the summer of 1828, the U. S. ship Natchez came into Pensacola Bay 
from a cruise. After lying at anchor for several weeks, the yellow fever 
broke out among her crew, and between fifty and sixty cases occurred. She 
was dropped down to the west end of Santa Rosa Island, and the men were 
placed under tents on its white sands, after which not another case occurred. 
Nobody in the town or Navy Yard was affected ; and the sloop-of-war Fal- 
mouth, lying in the same harbor, had not a single case. Dr. Hulse informs 
me, that this disease was pronounced yellow fever by all the surgeons then 
in the Bay. 

The Hornet. September, 1828. — After theU. S. Ship Hornet had been lying 
at anchor twenty-six days, near Sacrificios, a small island, about three miles 
from Vera Cruz, the yellow fever made its appearance among her crew. 
There was no epidemic in that city, except the dengue, nor had the vessel on 
her cruise touched at any place where yellow fever prevailed. During the 
two preceding months, the weather had been dry and oppressively hot.* 
In the preceding winter this vessel had undergone extensive repairs. She 
had been salted, and was very damp. On her return to New York she was 
broken out, and great quantities of mud and other filth were taken from her 
hold, and in her timbers and lower works, there was discovered a consider- 
able collection of chips and shavings, in a putrid state, which had fallen 

* Med. Stat. p. 58. 



232 THE PRINCIPAL DISEASES OF THE 

there during the repairs. The bilge-water and smell from the hold of this 
ship were exceedingly unpleasant.* 

It should be recollected that the temperature of the Gulf water in the 
latitude of Vera Cruz, in summer, is up to 82°, and of course that of the 
hold of the ship was the same. 

The Vincennes. 1831. — About the 6th of August, 1831, while the United 
States Flag-ship Vincennes, was lying in Pensacola Bay, the fever broke 
out among her crew. After twelve or fifteen cases had occurred, Dr. Hulse 
sailed from the Bay, but learned after his return, that many other cases 
occurred. The sick were taken to Camp Clinch. On examining the hold 
of the ship quantities of putrid rice, beans, and other articles which emitted 
a stench, were found. There was no spread of the disease. 

In 1828, the fever was moderately epidemic in New Orleans, and spora- 
dic in Mobile and Memphis; but did not occur elsewhere. In 1831, three 
cases only were admitted into the Charity Hospital, and none appeared out 
of New Orleans except those on the Vincennes. 

By these statements of Dr. Hulse and Dr. Barrington we are driven to the 
alternative of questioning their veracity, or admitting that yellow fever 
may be generated on board a ship. Those who know them personally, will 
be the last to hang on the former horn of this dilemma. 

X. Season of 1834. — This year, according to Dr. Hulse, and Mr. Wal- 
ter Gregory, now of Cincinnati, the Fever was epidemic, and did not limit 
itself like the last, to the town. The successor of Col. Noriega, mentioned 
above, an emigrant from New York, died of it, and cases occurred at the 
head of the Bay, and even in the pine woods. The army was now gone ; 
but it invaded the Navy Yard, and all the vessels lying in the Bay. 

Before any cases had occurred on shore, the crew of the U. S. Schooner 
Grampus began to sicken, on the 23d of August. She had been anchored 
in front of the town for several weeks. Six cases occurred the first day. 
The vessel was dropped down, and anchored off the Naval Hospital, to which 
the crew, sick and well, were transferred; every day a detachment of the 
latter was sent on board to purify and prepare the schooner for sea. The 
hold was foul and much of the flooring rotten ; at night a watch was kept 
on board. Regularly a part of these men were attacked with the fever, 
some of them while still at work, and others on the following day. By the 
11th of September eighteen cases had occurred, and in all, including some 
relapses, it was found at the end of the epidemic that there had been fifty- 
six attacks in a crew of sixty-two persons. Between the 27th and 31st of 
August another vessel, the Experiment, sent five cases to the Hospital, and 
afterwards nine more. She was a new and clean ship; up to the 12th of 
September, the other vessels lying in the Bay, remained exempt; but after 
that time, the disease appeared on every one. The number of patients 
finally in the hospital was seventy-eight. At the time it began to appear in 

* Assistant-Surgeon Barrington, U. S. N. American Journal, No 24, p. 307. 



INTERIOR VALLEY OF NORTH AMERICA. 233 

this vessel it attacked the inhabitants of Pensacola ; and proved fatal to a 
number. 

It does not appear that any vessel had come into the harbor from Cuba 
or any foreign port \ but schooners were then, as since, regularly plying 
between Pensacola and New Orleans, where the disease was epidemic that 
season. Was it then introduced from that city? No allegation of the kind 
seems to have been made ; and such an origin cannot be admitted, as the first 
case sent to the Charity Hospital that year was on the 28th of August, five 
days after the occurrence of the disease on board the Grampus, and when 
but four cases had been sent to that establishment, the disease was pre- 
vailing wherever there were people ;'on or around Pensacola Bay. It is 
worthy of remark that those two places were all which experienced a visita- 
tion this year. 

XI. Seasons of 1835, '6, '7, and '8. — Another period of immunity 
succeeded. The next four years did not present a single case. During this 
period it was once epidemic and once sporadic in Mobile ; twice sporadic and 
twice epidemic in New Orleans. One of these years, 1837, was signalized 
by a greater number of admissions, 1194, into the Charity Hospital than 
had ever occurred before ; and during its prevalence, the intercourse with 
the city was kept up. 

XII. Season of 1839. — It must be recollected, that this was the year 
in which the epidemic affected a greater number of places, than ever before 
or since. The town of Pensacola participated in the general visitation. The 
first cases occurred in unacclimated refugees from Mobile, who came with the 
semina of the disease in their systems. Subsequently it affected the 
resident population. Was this epidemic introduced by those who sickened 
with it after they arrived from Mobile ? This question could only be 
answered by a minute and accurate history of the first cases among the resi- 
dent population, and such an account I was not able to obtain. Prima facie, 
it was thus introduced; but in opposition to this conclusion we may refer 
to two facts, neither of which, however, is conclusive. First. The annual 
flight, always more or less considerable, of the unacclimated from New 
Orleans and Mobile to Pensacola, in years in which the last remained healthy. 
Second. The extensive prevalence of the disease in 1839, apparently indi- 
cating a yellow fever epidemic constitution of the air. 

But the disease was not confined to Pensacola. It occurred also on board 
the ship of war Levant, and in the Navy Yard. According to Dr. Hulse, 
about a dozen patients were sent from the ship to the Hospital. It was not 
known to him, that she had any more intercourse with the town than the 
other ships which were anchored near. Whether it appeared on her before 
or after it commenced in town, I cannot say. Of its occurrence in the Navy 
Yard, Prof. Carpenter, p. 27, on the authority of Prof. Wedderburn, gives 
the following account. 

" The first case that occurred at the Yard, was in a gentleman who had 



234 THE PRINCIPAL DISEASES OF THE 

just arrived from New Orleans, and who was sick at the house of Dr. , 

of the Navy. He died with black vomit, on the 5th of September. The 
Doctor himself, and a negro man who had nursed the gentleman, were 
taken sick simultaneously with the fever, a few days after his death. The 
next cases were other members of the Doctor's family, and several physi- 
cians and other persons, who attended on or visited the Doctor while sick. 
The infection then spread through the Yard." 

XIII. Season of 1841. — The year 1840 was exempt; but in 1841 the 
fever prevailed in the ships, the Navy Yard, and the town. 

The following is the account of Dr. Hulse : — * 

" The United States sloop-of-war the Levant came in from Vera Cruz, 
and as there were many cases of yellow fever among her crew, she was 
deserted, and the crew encamped in a large timber shed in the Navy Yard. 
The disease continued to prevail among the crew, but for two weeks it 
did not communicate to the inhabitants of the Yard. But at the end of this 
time it spread to the building nearest the shed, and finally through the 
Yard." 

There is a conflict of accuracy between this gentleman, and Professors 
Carpenter and Wedderburn, f as one says it spread through the yard, 
and the other, that only two well-attested cases occurred there; still 
further, while Professor Wedderburn represents that when the vessel 
arrived from Vera Cruz, there were many cases of the fever among her 
crew, Dr. Hulse informs us, that she was anchored opposite the town of Pen- 
sacola during the month of August, on the last day of which the first cases 
occurred. Dr. Laurison, the surgeon of the ship,J confirms the statement 
of Dr. Hulse as to the outbreak of the fever. " While lying," says he, 
" in the Bay of Pensacola, the yellow fever suddenly made its appearance 
on board the sloop-of-war Levant, of which I was the surgeon. The invasion 
of the disease was equally sudden and unexpected. On one day we were 
comparatively well, and in the evening had several cases of fever, which 
continued to develop itself among the crew and officers, until in the progress 
of the epidemic, out of a complement of 160 souls, not more than fifteen 
escaped an attack, in some form or other." After speaking of the landing of 
the men at the Navy Yard, and saying that this produced no abatement of 
the disease, he adds, " For a few days, the fever seemed to be confined ex- 
clusively to our ship's company ; but soon, however, some fatal cases occurred 
in the town of Pensacola, and on board the French vessels lying in the 
Bay." We are not told whether Prof. Wedderburn made his statement 
from personal observation or the report of others ; Dr. Hulse and Dr. Lauri- 
son wrote from personal observation. If we take their statement of the length 
of time which elapsed after the vessel reached the harbor of Pensacola, and 
manner in which the disease broke out, it was not introduced from Vera 

* Bait. Med. and Surg. Journ., April 1842, p. 392. f Sketches, p. 29. 

t Same Journal, June No. 1843, p. 393. 



INTERIOR VALLEY OF NORTH AMERICA. 235 

Cruz ; and as, according to both these gentlemen, it did not appear in Pen- 
sacola and on board the French ships till after it appeared on the Levant, it 
was not received bj the ship from the town, and must therefore have 
originated on board of her. It may be asked, then, Did not this ship infect 
the town, the Navy Yard, and the French ships ? This must be granted as 
possible ) but if the fever could originate in the first, it might originate in 
all the rest. If the Levant did not receive it from without, it is a pre- 
sumptive analogy that it did not communicate it. 

XIV. Seasons of 1842, '3, 4, and '5. — Exempt. Within those years 
twice epidemic in New Orleans and once in Mobile. 



SECTION VI. 

st. Joseph's, apalachicola bay, and tampa bay. 

I know nothing of the occurrence of yellow fever at the first and last 
of these places, but from a reference by Dr. Monette* to its occurrence at 
both, in the great epidemic season of 1839. Of the former place, he says, 
it was "ravaged/' of the latter, "many of its inhabitants died." No details 
are given nor authorities cited. Dr. Hort,f informs us that in 1826 some 
men died of yellow fever on Apalachicola Bay. They came from Baltimore 
with merchandise destined for the interior. There was at that time no set- 
tlement at Apalachicola, and no commercial intercourse with the West 
Indies. 



SECTION VII. 

KEY WEST, OR THOMPSON'S ISLAND. 



I. Season of 1824. — Key West, as a part of Florida, became a portion of 
the United States in the year 1821. Having a tolerable harbor, it was for a 
time made a naval rendezvous, and in 1824 the military and marine forces 
ordered there were very considerable. A number of armed vessels were 
anchored in the harbor, and the land forces were stationed on shore. According 
to Dr. Ticknor they were greatly addicted to intemperance, ate salted meats, a 
coarse seabread of a bad quality, and a few dry vegetables : their fatigue duty 
was exhausting ; and at night they lodged in the second story of buildings 
with roofs, but open on the sides, whereby they were exposed to the damp- 
ness, which, under the reduction of only 8 or 10 degrees of heat, in an atmo- 
sphere saturated with moisture, was very great. Such were the conditions 
under which the disease made its appearance. It affected almost every 
soldier or marine who lodged on the island, and some of the ships' crews 

* Observations, p. 122. f New Orleans Med. Journ. yol. ii. p. 5. 



236 THE PRINCIPAL DISEASES OP THE 

who came on shore; but none, as far as he knew, who remained all the time 
in the ships. The population of the village consisted of about sixty or 
seventy poor people, some of whom were blacks. Many of these inhabi- 
tants had long resided on the island, or in other places in the South ; but 
were now affected as well as those engaged in the public service.* We are 
not told at what time the disease commenced, nor whether any ship arrived 
there from Cuba or any other yellow fever port immediately before the onset 
of the fever. Indeed Dr. Ticknor writes of it as if it could have had no 
other than a local origin. We may presume that if any vessel having the 
fever had come into port he would have referred to the fact, although he 
might have denied the introduction of the disease ; but still it would have 
been more satisfactory to have been told whether it could have been then 
imported, supposiDg it an importable disease. 

The fever this year was moderately epidemic in New Orleans, and spora- 
dic in Mobile, prevailing nowhere else within our limits. Prof. Carpenter 
has not mentioned this epidemic. 



CHAPTER IV. 

LOCAL HISTORY— PLACES TO THE WESTWARD AND NORTHWEST OF 

NEW ORLEANS. 

Having completed the history of the origin of yellow fever in places 
east of New Orleans, let us now turn westward, by beginning with 

GALVESTON. 

Topography. — The medical topographer and yellow fever historian of 
Galveston, is Dr. Ashbel Smith ; j" but in addition to his valuable publication 
I have before me the notes of a conversation with Dr. Dickerson, now of 
Natchez, who at one time resided in the former. 

G-alveston is a long narrow island, separated from the continent by the 
bay of that name, and a narrow strait. Its general course is nearly south- 
west and northeast. Its elevation so little above the surface of the Grulf, 
that portions of it are liable to inundation when the waters are moved by 
strong winds. Composed chiefly of sand, it still has soil enough to support 
an herbaceous vegetation. At the depth of a few feet below the surface fresh 
water of a tolerable degree of purity may be obtained. 

The town is situated on the east end of the island. Its principal street, 
called the Strand, is on a flat terrace, or levee of sand, thrown up by the 

* North American Med. and Surg. Journ. vol. iii. p. 213. 

t An account of the Yellow Fever which appeared in the City of Galveston, in the Republic of Texas, 
in the autumn of 1839. 



INTERIOR VALLEY OF NORTH AMERICA. 237 

waves, in the rear of which and parallel to it, is a long narrow quagmire, 
which the tides overflow. Beyond this morass, the surface is higher and 
drier. Many of the houses are built over this morass, in which a great 
deal of filth is suffered to accumulate. The ships lie in front of the Strand. 
The latitude of the town is 29° 18' north, its longitude, 96° 6' west. 

Climate. — The mean temperature of G-alveston has not been made out. 
The south wind, directly from the Gulf, is balmy, with a clear sky. East 
and northeast winds are harsher; and the north and northwest winds, 
which begin to blow in October, bring great and sudden coldness. 

Age and Population. — Galveston may be said to have begun in 1836, 
and at the end of three years, it had about 2000 inhabitants, chiefly emi- 
grants from the United States, lodged in new frame houses. Throughout 
these years it remained exempt from yellow fever, and suffered but little 
from intermittents and remittents. 

Yellow Fever of 1839. — Throughout the summer of this year the 
town was healthy, the few violent cases of fever which occurred having been 
contracted elsewhere. 

On the 27th or 28th of September, according to Dr. Dickerson, a steam- 
packet arrived from New Orleans, with a case of what was regarded as yel- 
low fever. The patient died four days afterwards, without presenting decided 
symptoms of that disease. On the 28th, the cook of a vessel from Boston, 
anchored sixty or eighty feet from the steamer, was taken with fever. On 
the 1st of October he was brought to Dr. D.'s office. On the night of the 
2d he died with black vomit. While these cases were occurring, that is, 
within the month of September, according to Dr. Smith, Mr. Tickenor, 
who kept a retail store on the Strand, sickened and died with black vomit; 
and near the same time, Mr. Lang, living opposite Mr. Tickenor, sickened 
of the same disease, but recovered after having had hemorrhage from the 
gums. On the 27th, Mr. Abrahams was seized with the same, and when 
Dr. S. saw him on the 30th, his symptoms were well marked. He died the 
next day with hiccough, black vomit, and a yellow skin. Two other cases oc- 
curred almost simultaneously with this, and the 30th produced several more. 
The disease continued to rage till the 9th of October, when it was suddenly 
arrested for a period of two days and a half. 

" On the 30th of September, and for some days previously, strong east- 
erly winds prevailed, with cloudy weather throughout the twenty-four hours. 
From the 1st to the 5th of October, the wind blew from the east and north- 
east, in the morning, it hauled round to the southeast and near south, in the 
course of the day and evening, gradually becoming lighter, and dying away 
in the fore-part of the night, and regularly springing up about daybreak, with 
stiff breezes from the northeast and east. We afterwards had light south- 
easterly and southerly breezes, throughout the twenty-four hours, with occa- 
sional lightning and a few drops of rain about midnight, until the morning 
of the 9th October. At this time a stiff norther set in, with drizzling rains, 



238 THE PRINCIPAL DISEASES OF THE 

which lasted till the middle of the forenoon of the 11th. From the 30th 
September to the 9th October, the thermometer ranged at midday in the 
shade, from 84 to 88 degrees. On the 9th it stood at midday at 69£, on 
the 10th at 68£, on the 11th at 79, on the 12th at 80 degrees. Within the 
fifteen hours immediately preceding the norther and fall of the mercury, I 
was called to eight new cases, and I have been informed of some others. 
During the prevalence of the norther, I do not believe, after careful inquiry, 
a single new case occurred. Subsequently the epidemic reappeared in a 
somewhat mitigated form — the first fresh attack recurring, I believe, about 
5 p. M. on the 11th. Subsequently to this date the thermometer ranged 
generally from 80 to 85 J degrees at midday — descending one day as low as 
70 degrees, with variable winds, chiefly between the northeast and south, 
until the morning of the 5th November, when a stiff norther set in, which 
blew three days. The thermometer on the 7th stood at 45 degrees in the 
morning, and 58 degrees at midday. There was on the night of the 6th 
and 7th a slight frost, which it is hoped has put an end to the epidemic. It 
may be observed here, that although the northers prevented new cases, they 
were believed to be pernicious to persons previously attacked." 

According to both Dr. Smith, and Dr. Dickerson, the people who lived 
beyond the morass and did not visit the Strand, remained free from the 
disease. The latter states that the mate and two of the crew of the steamer 
from New Orleans, died of the fever, in the course of the epidemic. 

Dr. Monette* and Prof. Carpenter*)* inform us that the fever was in- 
troduced from New Orleans, but do not assign the vessel. Dr. Dickerson, 
however, supplies the omission, by designating the steamship which arrived 
from that city on the " 26th or 28th." Dr. Smith, on the other hand, is silent 
as to importation, and evidently regards the disease as of local origin. From 
a comparison of dates it is quite obvious that if it were imported, the ves- 
sel that brought it has not been discovered; for, first, it was not certain that 
the patient in the vessel referred to really had yellow fever j and second, 
several cases occurred on the Strand so early as to prove fatal even before 
the death of that patient. 

On the whole we may conclude that as both the alleged conditions, local 
filth and commercial intercourse with a city where the fever prevailed 
were present at Galveston, the origin of this epidemic remains undetermined. 

Season or 1844.— [MSS. wanting.— Ed.] 

FRANKLIN. 

Season of 1839. — Franklin, although maintaining at all times a regular 
commercial intercourse with New Orleans, seems to have had no visitation 
of yellow fever till this year, though there is a -traditional account of some 
cases twenty years before. The account given by Dr. Monette,J on whose 
authority he does not tell us, is as follows : — 

* Observations, p. 115. t Sketches, p. 27. $ Observations, p. 111. 



INTERIOR VALLEY OF NORTH AMERICA. 239 

" This town, like all the interior towns, was uncommonly healthy during 
the summer until after yellow fever had become epidemic in New Orleans, 
and many persons flying from that disease had arrived from the city about 
the 1st of September. In addition to which, in the first week of September, 
a steamboat arrived from New Orleans with many persons on board, seve- 
ral of whom were attacked soon afterwards with yellow fever, besides two 
cases which developed themselves on the way, one of which died before the 
boat reached Franklin. This boat proved to be infected ; for several per- 
sons died who had not been exposed to any other source of infection, and 
who were attacked with yellow fever a few days after having made a visit 
to this boat. The clerk of the parish court was one of them. In less than 
a week after this boat arrived at the landing, several persons in that imme- 
diate vicinity took the disease, and also died. The disease was considered 
epidemic after the 15th of September, and did not cease until checked by 
frost early in November. The number of deaths in the village and vicinity 
was about twenty-five ; the whole number of cases about forty-five." 

Prof. Carpenter,* on the authority of Mr. Wilson, a citizen of the place, 
gives the following account. 

" Introduced from New Orleans, under the following circumstances. 
Direct communication, between New Orleans and Attakapas, is seldom 
open, until towards January, and then the boats run through the Bayou 
Plaquemines. In October, 1839, the steamer Tomochichi was placed on the 
sea route. On her first or second trip from New Orleans, where the yellow 
fever was epidemic, to Franklin, Henry Thompson, of the latter place, was 
among the few persons who went on board of her. He was taken sick with 
yellow fever in a few days afterwards, and was the first who died with black 
vomit in the village. It was remarked, that nearly all those who visited 
him took the disease, and many of them died. Mr. BirdsalFs family were 
all particularly attentive to him, and they were all ill, and several of them 
died. The neighbors who visited Mr. B/s family were all taken sick, and 
the disease throughout could be traced by infection from one case to 
another." 

It is difficult to reconcile these statements. That of Dr. M. represents 
the steamboat to have arrived the first week of September, that of Prof. C. 
in October, two weeks or more after the fever, according to Dr. M., had 
become epidemic. The latter gentleman states that she arrived with the 
corpse of one person who died of the fever, and one patient laboring under it ; 
Prof. Carpenter is not only silent on these cases, but his narrative even seems 
to preclude their existence ; the former tells us that several persons were 
attacked with the fever a few days after having gone on board the boat, 
and that in less than a week after her arrival, several others residing near 
the landing were taken down ; but the latter tells us, that Henry Thomp- 
son was among the few persons who went on board of her, that he was the 

* Sketches, p. 27. 



240 THE PRINCIPAL DISEASES OF THE 

first who died in the village, and that the epidemic spread from him. 
These are evidently two distinct histories; and I now proceed to add a third. 

When at Plaquemines, head of the Bayou of that name, in May, 1844, 
I met with Dr. Joseph L. Horsby, then a resident of that town, but in 
1839, residing in or near Franklin, who gave me the following statement. 

Henry Thompson, mentioned by Prof. Carpenter's correspondent, was 
the first individual attacked with the fever, nearly all the characteristic 
symptoms of which were present, except hemorrhage and black vomit. 
He was clerk of the Court, as stated by Dr. M., proving that he and Prof. 
C. refer to the same boat, and also, assessor of parish taxes, and in the pro- 
secution of his duty he had ridden over the prairies for two weeks in the 
hot sun. On the 2d day of September, two days after his return home, 
and without having been on board any steamer, he was taken down, and died 
on the night of the 7th. The steamer Tomochichi arrived on the morning he 
was buried. The steamer was said to have a case of yellow fever on board. 
She laid at the wharf only a few minutes, landed some goods, and resumed 
her voyage up the Bayou Teche. 

Dr. H. attended the patient Thompson, and collected his history. No 
other case occurred till the 22d of September, a fortnight after the funeral 
of the person just mentioned, when two others were taken down on the same 
day, and both died. They were attended by himself and his partner, Dr. 
Ethan Allen. Of these two patients, one was an elderly lady, who seldom 
went from home ; the other, Anderson, a clerk in a store, which had not re- 
ceived goods by the boat from New Orleans. This young gentleman boarded 
in the family of Mrs. Birdsall, mentioned by Prof. C/s informant. That 
gentleman had been to the Eastern States, and reached home the night that 
Anderson died. On the 26th, an itinerant dentist, last from St. Martins, 
on the Bayou above, after having been only three or four days in the village, 
was seized and died with black vomit, in the house of Mr. Scott. On the 1st 
day of October, Birdsall was not well, and his wife on the 2d had an attack of 
the fever, from which she recovered. On the 5th he went a mile into the 
country, to the house of Mr. Parkinson, where he got worse, and died on 
the 9th. On the 15th Mr. P. was taken sick, but not with yellow fever; 
his family remained in health. On the 28th of September, Northrop, who 
during Thompson's illness was in the country, suffered an attack, which 
proved fatal on the 1st of October, with black vomit. No other member of 
the family had the disease. On the 4th of October, Hartman, a Creole, 
who had visited Thompson, was seized, and expired on the 10th, but his 
family remained healthy. On the 8th of October, Johnson, who had had no 
special intercourse with any of the sick, was attacked, but his family 
escaped. On the 3d of October, Mrs. Dwight, who lived two miles in the 
country, came into town and went to Mr. Scott's, where the dentist had 
died three days before. On the 8th she was attacked, and died on the 11th, 
with all the characteristic symptoms ; but no member of her family or 



INTERIOR VALLEY OP NORTH AMERICA. 241 

the friends who visited her, were affected. On the 16th, the undertaker 
who up to that date had buried nearly all the dead was seized. On the 27th 
Dr. H. was taken down, and his partner, Dr. Allen, in a week afterwards. 
His was among the last cases which occurred. 

The dates of these cases were transcribed from Dr. Horsby's books. They 
do not embrace all that occurred in the village, the number of which was 
twenty-eight. The aggregate population was about four hundred, including 
negroes and mulattoes. Three or four of the former experienced attacks, 
from which they recovered : one of the latter died. Dr. Horsby affirms 
that he knew of persons who came in from the country, and only walked 
the streets without entering a house, who were seized with the disease after 
they returned home. 

In looking at the three histories of this visitation, we are compelled, I 
think, in the absence of other testimony, to admit, that, although the fever 
may have been imported, the case is not made out, and that we must look 
elsewhere for decisive facts as to its origin. 

NEW IBERIA. 

Season of 1839. — I have no account of yellow fever in this village before 
that of 1839. Of its appearance there, Dr. Monette,* on the authority of 
the Hon. B. Gr. Teany and other intelligent men, gives the following account : 
" This village continued very healthy until the 10th of September, when 
cases of yellow fever began to present themselves in the persons of those 
who had recently arrived from New Orleans, by way of the Plaquemines. 
Such were the first cases of yellow fever in New Iberia, in 1839. I am not 
apprised that the disease was ever there before. 

Soon after the first cases of this kind, the disease began to spread among 
those of the place who had been exposed to no other source of infection 
than the steamboats, the sick, and the fomites imported in those boats. The 
whole number of deaths, in and near this town, was about twenty. 

In support of this statement, I have received from Dr. Abbay, now of 
Port Gibson, Missouri, but in 1839, of New Iberia, the following narrative. 
Although a regular steamboat intercourse, twice a week, had been maintained 
between Iberia and New Orleans, where the fever had been epidemic for 
six weeks, by the Mississippi River and Bayou Plaquemines, no case of the 
fever had been seen in the former up to the 10th of September. On the 
night of that day, the steamship Tomochichi already mentioned, landed 
at the wharf of the village, with a patient far advanced in a fatal attack of 
the fever. Dr. A. was called to see him, and on the night of the 12th, 
Mrs. A., who had not seen him, sickened with the disease, contagion having 
been introduced as it was assumed by adherence to the clothes of her hus- 
band. On the same night, three gentlemen who had been much around the 
patient, were taken down with the fever. On the night of the 18th or 19th 

* Observations, p. 113. 
VOL. II. 16 



242 THE PRINCIPAL DISEASES OF THE 

seventeen persons who had been much exposed to the atmosphere of the 
other patients, were taken down, and the next day Dr. A. himself was seized. 

Prof. Carpenter,* however, gives, on the information of Drs. Cook and 
Taylor, of Opelousas, who had it from others, a different statement. " The 
circumstances of the introduction of yellow fever into this village in 1839, 
we are told are as follows : A young physician, Dr. Smith, died of the dis- 
ease at Plaquemines, and his remains were carried to his friends in New 
Iberia, and were exposed in the village church, according to the usages of the 
Catholics. Many persons who entered the chapel for the purpose of seeing 
the remains, or for other purposes, took the disease, and many died with 
black vomit, and the disease was communicated from them to others." 

From Daniel Avery, Esq., of Baton Rouge, who at that time was a 
sojourner in New Iberia, I have received an account substantially the same as 
that given by Prof. Carpenter. The tin coffin in which the remains of Dr. 
Smith were enclosed was so badly made that an offensive fluid oozed from it, 
so Mr. Avery and a number of others had it removed to a sugar-house out 
of the village, and thence carried to the grave. At that time there was no 
fever in the village, but soon after the funeral all who attended were at- 
tacked, except himself and another, who had experienced the disease before. 

From Dr. Clements of Plaquemines I learn that Dr. Smith died on the 
12th, the very day on which several cases occurred in Iberia. Thus if the 
exhibition of his remains two or three days afterwards excited the disease 
in the people of Iberia, it was introduced into that village in two different 
and successive modes. But are we at liberty to conclude that it was in fact 
introduced by either ? If so contagious as that Dr. A. could by visiting a 
patient transmit it to his wife, how could it have happened that it should 
have been mortally prevalent for six weeks in New Orleans before it was 
carried to Iberia? And what reason can be assigned for its nearly simulta- 
neous appearance in most of the smaller towns of the delta of the Mississippi 
about the 8th or 10th of September. 

ST. MARTINSVILLE. 

Till 1839, as Dr. Monettey informs us, yellow fever had been unknown 
in St. Martinsville ; but several cases now occurred in fugitives from New 
Orleans. It did not, however, become epidemic in the village. Whether 
any cases occurred among the resident population does not appear. Prof. 
CarpenterJ merely says, u Introduced from New Orleans." 

OPELOUSAS. 

Tbe first occurrence of yellow fever in this town was in the 
Season of 1837. — The following account from Dr. T. A. Cooke of that 
place, in a letter to Prof. Carpenter is all that I know of this invasion. 

* Sketches, p. 28. t Observations, p. 114. t Sketches, p. 28. 



INTERIOR VALLEY OF NORTH AMERICA. 243 

" In the fall of 1837, the yellow fever for the first time appeared as an 
epidemic in the town of Opelousas. The first resident who took the disease 
and who died with all the symptoms of yellow fever was a tailor by trade, 
named Emile Bassant. He was taken sick about the 20th of October, and 
died on the 28th. A short time before his attack, but how long cannot 
now be well ascertained, he had given his personal attentions in Gabriell's 
Hotel, near his residence, to a stranger who had come directly from New 
Orleans, and who speedily after his arrival in Opelousas was violently 
attacked with fever, which terminated fatally in a few days with the black 
vomit. The next case was that of Victor Miramond, resident for many 
years, who attended Emile Bassant in his dying moments, and followed the 
corpse to the grave. In about twenty-four hours after the funeral he was 
violently attacked, and in four days he was dead. He threw up an immense 
quantity of black matter. From and after the 1st of November, the disease 
gradually extended for some three or four weeks, after which period it 
gradually subsided, but did not disappear until after several severe frosts." 

It is to be regretted that Dr. Cooke did not say whether the gradual ex- 
tension of the fever occurred successively from those antecedently affected. 
The fact as it stands goes strongly to establish the contagious character of 
the disease, but the two persons he has named might have been taken down 
if the patient from New Orleans had not come, provided the disease origi- 
nated independently of contagion. 

Season of 1839. — The next invasion at this place was in 1839, and was 
made, according to Dr. J. A. Taylor, in the following manner :* On the 16th 
of August, Fisk, an unacclimated man, who had spent four or five days in New 
Orleans and then departed for Opelousas, was brought from the landing to the 
village. He was ill of a fever that did not show the symptoms of ordinary au- 
tumnal fever, and Dr. Taylor requested Dr. Cooke and Dr. Jewell to attend 
in consultation. On the 21st he died with black vomit. From that time 
till the 14th of September, twenty-four days, the fevers in Dr. Taylor's 
practice were of a mild and manageable character; but Dr. Hill informed 
Dr. Carpenter (p. 61), that on the 2d of September, twelve days after the 
death of Fisk, Hartshorn, who nursed him and attended to the funeral ar- 
rangements, sickened and died with black vomit on the 7th. Immediately 
after the 14th the fever became epidemic. Dr. Taylor has given the dates 
of his cases for a week, but makes no reference to their having had com- 
munication with Fisk, Hartshorn, or any other affected. He informs us, 
however, that all the inmates of the hotel in which Fisk died had the dis- 
ease, but at what time it commenced among them he does not state ; of 
course it was not, as we have just seen, till after the twenty-fourth day from 
Fisk's death. He also informs us that when it appeared in a family, it was 
apt to attack the whole. It was fatal to nurses, of whom one of his patients 

* Sketches, p. 59. 



244 TOE PRINCIPAL DISEASES OF THE 

bad three in as many days, each being taken down on the day of entering 
on duty. 

I cannot concur with Prof. Carpenter in the conclusion that these facts 
establish the importation of the fever into Opelousas. The lapse of twenty- 
four days after the death of Fisk, during which but one case of the fever 
occurred, and its sudden epidemic prevalence immediately afterwards, seem 
to me irreconcilable with the known laws of contagion. It will be observed, 
moreover, that this epidemic invasion was nearly cotemporary with that 
of Franklin and Xew Iberia, and nearly two months after the disease had 
begun to prevail in Xew Orleans, during which time there had been con- 
stant intercourse between the two places. Dr. Alonette,* apparently un- 
acquainted with the detail of facts here given, by the medical gentlemen 
of Opelousas, presents us, but on what authority we are not told, with the 
following history : — 

" This village has loug been a resort for many of the inhabitants of 
Xew Orleans, when compelled by the epidemic to retire from the city ; and 
in no case have I been able to learn that yellow fever has been ever com- 
municated, in its epidemic form, to the inhabitants, until the autumn of 
1839. This year the health of the place was uninterrupted until the 1st of 
September, when cases of this disease began to manifest themselves in the 
persons of those who had recently arrived from Xew Orleans. For ten 
days it was confined exclusively to the people of Xew Orleans, and those 
recently returned from that city, with whom the village was thronged. 
Cases multiplied daily, and by the middle of September it was considered 
as epidemic, when most of the people deserted the place. The disease was 
epidemic until Xovember, when the number of deaths had increased to 
forty-seven, of whom seventeen were natives of the place." 

It cannot but appear remarkable that Dr. Taylor should have been igno- 
rant of this prevalence of the disease through the first two weeks of Septem- 
ber, and that another physician, Dr. Hill, should have known of but a single 
case, and the patient not one of those who came from Xew Orleans. The 
continued contrariety between Prof. Carpenter and Dr. Monette, relative 
to the appearance of the disease in the towns of the Bayou Teche, is indeed 
well calculated to diminish confidence in the accuracy of their informants. 
It shows indeed that in each of those towns there was difference of opinion 
as, to the mode of origin of the fever. Ail this is very much to be regretted, 
as, from their detached position and limited population, it might have been 
expected that the question of importation would have been there definitively 
settled. 

Season of 1842. — The following is Dr. Carpenter's account of the onset 
of this epidemic : — 

'•'Introduced from Xew Orleans. The first case was a French peddler, 
named Etienne Franquez, who had been to Xew Orleans, where the disease 

* Observations, p. 114. ' 



INTERIOR VALLEY OF NORTH AMERICA. 245 

was prevailing; he was attacked on the day of his arrival at Opelousas, and 
died with black vomit. 

" The second case was Chassan, clerk in the store of Chaudet, who had 
given his personal attention on Franquez, and watched with him one or 
more nights. He also had black vomit before his death. 

" The third case was Renaud, clerk in the store of Blanchin, Riche & Co., 
had visited both of the first cases. He died with black vomit. Other 
cases immediately succeeded, and the disease soon became epidemic. " 

ALEXANDRIA. 

The transition from Opelousas to this place is not unnatural, as the dis- 
tance is not great, and they both lie off to the west of the Mississippi River. 

Alexandria is situated on the right bank of Red River, in north latitude 
about 31°18', at the distance of 100 miles up that river, and 336 from New 
Orleans. 

I am indebted to Dr. Monette* for all that I can say concerning yellow 
fever at this place. It appears never to have occurred till the remarkable 
epidemic in the year of which I am about to speak. 

Season of 1839. — In July, the weather was insupportably hot and very 
dry, but healthy. But the river was high and continued so through the 
month of August, — swarms of emigrants to Texas meanwhile adding to 
the population of the town and that of the boats. Early in September, every 
day's steamboats brought persons from New Orleans with the semina of the 
fever in their systems. Cases of the fever immediately began to manifest 
themselves in the boarding-houses near the landings, and by the 20th it was 
prevalent over the whole town, and raged till checked by cold weather about 
the 1st of November. The majority of all the deaths and cases occurred 
among emigrants, boatmen, or transient persons from New Orleans. Persons 
who imprudently ventured into the city, were attacked on returning home. 
Dr. Jackson and others assured Dr. Monette that there was not a case in 
town till after the disease had appeared on board three steamboats that plied 
between that place and New Orleans, and that the first spread of the disease 
was from the boarding-houses where patients from these boats had been 
left. 

NATCHITOCHES. 

This old Spanish and French village is seated on the same river, 150 
miles higher up. In the month of August, 1839, several persons from New 
Orleans had the fever in that town, but no case occurred in its own popula- 
tion, which amounted to about 500. The town is built on the margin of 
a fine ancient alluvion, skirted by rolling pine lands in the rear. The fall 
of the river by the 1st of September, prevented the ascent of boats to this 
place after the month of August."}* 

* Observations. f Ibid. p. 108. 



246 THE PRINCIPAL DISEASES OP THE 

On these two accounts I may remark that yellow fever appeared in Alex- 
andria under the combined influence of a crowded population, busy wharf, 
and the arrival of boats with yellow fever from New Orleans. In Natchi- 
toches, only one of these influences, namely, the importation of yellow fever 
cases, existed, and yet the fever did not spread among the residents. It ap- 
pears then, that the fever of 1839, at Natchitoches, was not contagious — 
could not propagate itself; why then did it propagate itself in Opelousas? 

THIBODEAUXVILLE. 

Season op 1839. — Prof. Carpenter is silent as to yellow fever in this 
village. Dr. Monette, p. 102, informs us that, as the water, at the efflux 
of the Bayou from the Mississippi, at Donaldsonville, was in autumn too 
shoal to admit of the passage into it of the New Orleans steamers, the boats 
on the Bayou ascended, but did not pass out of it, bringing down persons to 
Thibodeauxville. 

In this place the population enjoyed uninterrupted health, in the fall of 
1839, until many persons arrived from New Orleans, towards the last of 
August, for retirement from the epidemic. The first five or six cases of 
yellow fever were unquestionably in persons recently from that city; and 
none pretend to question the fact that these cases were introduced from 
New Orleans. Cases occurred subsequently during the month of September, 
until the whole number was about twenty-five. Some of the latter could 
not be traced to New Orleans, but to infection or fomites introduced from 
that city. The disease did not prevail as an epidemic, for the greater 
number of cases were contracted in New Orleans. Mr. W. B. Shields, an 
intelligent planter in that region, assures me of these facts. The number 
of deaths in this town was about fifteen. 



CHAPTER Y. 

PLACES UP THE MISSISSIPPI FROM NEW ORLEANS. 
DONALDSONVILLE. 

We now come back to the Mississippi Biver and find ourselves on its right 
bank, at the efflux of the La Fourche, in the latitude of New Orleans, and 
seventy miles above that city. 

Season of 1839. — Being the first town above New Orleans, and situate 
at the mouth of a navigable bayou, the banks of which have long been 
thickly inhabited, and where transshipments are made, no place could have 
been more exposed to any influence which New Orleans can exert on other 
places, in yellow fever seasons, than this, and still it was not till 1839, that 



INTERIOR VALLEY OF NORTH AMERICA. 247 

it experienced the fever. Of this visitation, Prof. Carpenter gives us no 
details, but Dr. Monette* has the following statement : — 

" During the summer of 1839, Donaldsonville, like all other towns on the 
Lower Mississippi, was remarkably healthy until the 1st of September, when 
yellow fever had been epidemic in New Orleans for more than two weeks. 
This state of health continued uninterrupted until after ten or twelve 
cases of yellow fever had been introduced from New Orleans by the boats, 
besides a few persons who arrived from the city with the infection dormant 
in their systems, and soon after were attacked by fully-developed yellow 
fever. These cases were all taken to the public hotel, or to other houses 
in that vicinity, and near the steamboat landing. At length, towards the 
middle of September, the local atmosphere was contaminated, or infected, 
and other persons who had not been exposed to any other source of infection 
contracted yellow fever and died, after having been more or less in the 
newly -infected district. The remainder of the town continued healthy. 
Among the first persons attacked in Donaldsonville, after the first imported 
cases, were several persons who had visited, nursed, and sat up with the sick. 
The disease continued to spread slowly until frost, when about thirty 
deaths had occurred, besides the first imported cases. This statement is 
given upon the authority of Col. H. T. Williams, Surveyor-General of 
Louisiana, and of Mrs. C. M. Thayer, both residents of that town." 

I have three remarks to make on this statement. The disease began in 
New Orleans on the 23d of July, and prevailed more in August than any 
other month of the season, 482 patients having been admitted into the 
Charity Hospital in that month, while only 361 were received in September, 
yet it was not till the middle of the latter month, nearly eight weeks after 
its advent in New Orleans, that it began among the resident population of 
Donaldsonville, notwithstanding the daily intercourse. What cause prevented 
an earlier play of the contagion ? Now the middle of September, as we have 
seen, was the time when it became epidemic in the towns on the Bayou 
Teche. 2d. It appears that there was a district in Donaldsonville, whose 
atmosphere gave the disease to those who visited it, the remainder of the 
town having a salubrious atmosphere. 3d. Among the first persons 
attacked after the imported cases, were several who had visited, nursed, and 
set up with the sick, from which it appears that the disease occurred in others 
who had not been thus exposed. 

Seasons op 1840, '1-3. — Dr. Sabin Martin informs me that in 1840, 
when scarcely a case occurred in New Orleans, a man came from that city 
to Donaldsonville, sickened there, and died with all the characteristic symp- 
toms of the fever, but no other case followed. 

In 1841, a family left Baton Rouge, in a flat-boat, for Donaldsonville. 
There was no yellow fever that year in the former town, or in the interme- 
diate town of Plaquemines. This family had been two years from France. 

* Observations, p. 95. 



248 THE PRINCIPAL DISEASES OF THE 

When they reached Donaldsonville, the father and his oldest daughter were 
ill with the fever. Dr. M. was called in, and found the former walking 
about his room, and saying he was not sick. In three days, however, he 
died with black vomit, and his skin became yellow after death. The 
daughter had all the characteristic symptoms of yellow fever, and died in 
four days, previously to which, she had suppression of urine, her skin be- 
came yellow, and she threw up great quantities of black vomit. The mother 
and two younger children escaped the disease. Dr. Cotman, apart from Dr. 
Martin, gave me the same account. No other cases followed. The fever 
was this year epidemic in New Orleans, Pensacola, Port Hudson, above Baton 
Rouge, and Vicksburg. 

In the autumn of the year 1843, a young woman, from the country parish 
of St. James, below Donaldsonville, came to the neighborhood of the latter 
place, in the month of October, where she sickened and died with the cha- 
racteristic symptoms. 

Earlier in the season, a man on Front Street died of the disease, but did 
not communicate it. A German, also, died of it in the midst of a house full 
of his countrymen, who escaped. There was no allegation at the time of 
these patients having been on board of boats from New Orleans. 

In the latter part of October, Duchesne, a play actor, who had left New 
Orleans three months before, to escape the fever, was seized with it. Im- 
mediately before the attack, he had been for some time fowling around a 
lake several miles in the rear of Donaldsonville. He expired in three days 
and three hours from the sudden commencement of his disease. In twenty- 
eight hours from the beginning, he had great irritability of stomach, head 
and back ache, and a yellow skin ; in thirty-six hours more, suppression of 
urine and black vomit; fourteen hours before death, he suffered from a 
slight hemorrhage. This patient had not been near any one with the fever. 
Nobody took it from him. — Dr. Martin. 

Here, then, we seem to have genuine cases of yellow fever, not traceable 
to contagion or fomites. In the case of the play actor, it must be admitted 
as a possibility that his system was impressed by the remote cause before 
leaving New Orleans. The young woman from the parish of St. James might 
have visited New Orleans after the disease became epidemic; and the German 
and the tinner on Front Street might have gone on board of steamers from the 
city, and therefore their cases cannot be referred to as examples of origina- 
tion from endemic causes; but in the case of the Frenchman and his 
daughter, there appears to be no room for any such suppositions. 

This year the fever was epidemic in New Orleans, Mobile, St. Francis- 
ville, Port Hudson, Rodney, and Vicksburg, and sporadic in Baton Rouge, 
as well as Donaldsonville. 

PLAQUEMINES. 

I am indebted to Dr. Charles Clements, who, after residing for three years 



INTERIOR VALLEY OF NORTH AMERICA. 249 

in the vicinity, removed into the village of Plaquemines, in the year 1820, 
for four notices of yellow fever in this place. 

Season of 1829. — Dr. Clements thinks that sporadic cases of the fever 
had previously occurred here, but the first epidemic was in 1829. It was 
alleged that the disease was introduced by Aborn, a man from New Orleans, 
who arrived unwell on the 4th of August, and had a mild attack, from which 
he recovered, Dr. C. being his physician. But, on the 31st of July, a Creole 
planter of the neighborhood, after having played billiards all night in town, 
was seized with the fever, and died in four or five days, with yellow skin 
and black vomit. This was the first case. The second was that of Hanna, who 
was taken on the 3d of August, and died with the characteristic symptoms 
in three or four days. Nothing was said of his having been on board a 
steamboat. Quite a number were seized about the same time, in different 
parts of the town. Those who were receiving and forwarding goods, were 
not more affected than others. The Creole who died had not received any. 
During the epidemic, three men came from the country, and remained in 
town all night. The whole suffered attacks after returning home, and two 
died, but no one took the disease from them. 

This year the disease began in May, and continued to appear in June. It 
was decidedly epidemic in New Orleans and various other places on the Gulf 
and river coasts. Neither Professor Carpenter nor Dr. Monette has noticed 
the visitation at Plaquemines. 

Season of 1833. — In 1830, the fever was epidemic in New Orleans, and 
in '31 and '32, slightly sporadic, but Plaquemines remained exempt. In 
1833, the city suffered a violent invasion, and Plaquemines was the only 
other place affected ; it was, however, sporadic. A young man, Desbrow, 
came from the city and died with it, but there had been cases before his 
arrival. 

Season of 1837. — Between this and the preceding epoch, the disease 
was twice epidemic at New Orleans, but Plaquemines remained free. This 
year there were a few cases, but no allegation of its being introduced. 

Season of 1839. — The autumn of 1838, as far as Dr. Clements recol- 
lects, presented no case ; but in that of 1839, there were more cases than 
in '37. Dr. Smith, whose case was mentioned when speaking of New Iberia, 
was its first victim, and he was taken on the 7th of September. Thus it 
appeared about the same time here as on the Bayou Teche. It prevailed 
chiefly in the lower part of the town, and not in the vicinity of the steam- 
boat landing. It was not alleged to have been imported. Dr. Monette, 
however, informs us that the u village was entirely free from any disease 
until after several yellow fever patients had been landed by boats from New 
Orleans." 

The following years, up to 1845, inclusive, were exempt. In 1842, as 
Dr. Hiriart informed me, a sick man was brought on shore from a flat-boat 
descending the river. He died in a boarding-house with black vomit, but 



250 THE PRINCIPAL DISEASES OF THE 

no one took the disease. In 1843, another case of the same kind, but no 
spread of the disease. In September, 1843, as the same gentleman told 
me, a Creole, living on the opposite side of the river, spent an hour on board a 
steam-packet bound from New Orleans to Baton Eouge, the fever prevailing 
in both places. He had influenza at the time. Symptoms of yellow fever 
supervened on the second day after his visit, including, before he died, 
yellow skin, suppression of urine, and black vomit. None of his family 
contracted the disease, but it was said that a relative, who visited him, did. 
As Dr. Hiriart had spent four years in the Charity Hospital of New Orleans, 
I cannot doubt his accuracy. 

BATON ROUGE. 

Dr. French went to reside in this old French village in 1808, and did not 
see a case of yellow fever till the year 1817, when he was himself attacked ; 
showing that a residence of nine years in the South had not given to his 
constitution a power of resistance to the remote cause of this malady. From 
this gentleman, as well as from Dr. Harney, Surgeon U. S. A., who has 
been stationed at the barracks of this post most of the time since 1818, I 
learn that there are no traditional accounts of the fever at an earlier date 
than that just mentioned. Meanwhile, it had been epidemic in New Orleans 
seven times. I also learn from two citizens, whose memory goes back as 
far as Dr. F.'s residence there, the same thing. These gentlemen will be 
my chief authorities. 

Season of 1817. — The fever was epidemic this year, but I have not been 
able to obtain any history of its rise. It was also epidemic in New Orleans 
and Natchez. 

Season of 1819. — Again epidemic, but no history of it can be written. 
Prevailed at the places just mentioned, and also in Mobile. 

Season of 1822. — Epidemic and mortal. More than sixty deaths. No 
history. Prevailed, also, in New Orleans, and on Mobile and Pensacola 
Bays. 

Season of 1827. — Sporadic in the latter part of autumn. — Harney. 
Prevailed in New Orleans and Pensacola as an epidemic, and sporadically in 
Mobile, Bayou Sara, Natchez, and Yicksburg. 

Season of 1829. — From 1817 to 1829, although yellow fever had ap- 
peared in New Orleans every year except two, it visited Baton Rouge but 
four times. In 1825, when the fever broke out in the city, it extended to 
the troops in the New Orleans barracks, which, after the occurrence of three 
cases, were, on the 1st of August, removed to Baton Rouge, where they con- 
tinued in good health.* Its fifth visitation was this year, and its intro- 
duction, according to Prof. Carpenter, f as follows : — 

" This year many Spaniards fled to New Orleans, in consequence of the 
political revolution which had taken place in Mexico. Soon after their arrival 

* Statistics of U. S. Army. p. 46. f Sketches, p. 26. 



INTERIOR VALLEY OF NORTH AMERICA. 251 

in New Orleans, the yellow fever appeared, and they removed to Baton 
Rouge. But they had been exposed to the infection, and the yellow fever 
appeared among them about the time of their arrival at Baton Rouge, and 
many of them died. The disease was soon communicated to the resident 
population, and raged with great mortality. " 

When in Baton Rouge, I made every possible effort to obtain a detailed 
account of the origin of this epidemic, but after the lapse of fourteen years, 
and the removal of most of the Spanish exiles, the acquisition of full and 
correct information was impracticable. The epidemic was one of the earliest 
which New Orleans has experienced, for a patient was admitted into the 
Charity Hospital on the 26th of May, and by the 7th of June, the twelfth 
had been introduced. As to the time when the Mexican refugees left New 
Orleans, I could not acquire specific information, but was assured that they 
began to come in the spring, and continued coming till in the summer, con- 
sequently till after the time when the fever had begun to prevail in New 
Orleans. I could not learn that any of them had the fever at the time of 
their arrival. All accounts agree that it was chiefly among them, which Dr. 
Harney* ascribes to " their mode of living, their filth, and their crowded 
condition." It is certain, however, that a number of citizens and soldiers 
died of the disease, and it appears to have affected them first. If the fever 
had never prevailed there before, these facts would certainly seem to indi- 
cate its importation. The fever was epidemic this year in Mobile, Plaque- 
mines, St. Francisville, and Bay of St. Louis, and sporadic in Natchez. 

For the ensuing thirteen years, after 1829, Baton Rouge remained 
exempt, during which the fever was eight times epidemic in New Orleans. 
Prof. Carpenter has marked it as prevailing in 1837, but Dr. Harney and 
Dr. French assured me that it did not. In 1839, when it prevailed so ex- 
tensively throughout the South, Dr. Harney observed, both in town and 
country, a mild fever, in which the patients frequently vomited a dark- 
colored fluid, which, however, had not the characteristics of true black 
vomit. 

Season of 1843. — Dr. Harney informs me that it prevailed this season 
chiefly in the garrison, where there was great mortality in proportion to the 
number of cases. He does not admit the existence of any facts showing 
that it was imported. Prof. G.f says — " The disease appeared here in Oc- 
tober. There was daily communication with New Orleans." 

This is equally true of the eight years just mentioned, when no fever 
appeared in Baton Rouge. The seasons of 1844-5 were exempt. 

PORT HUDSON. 

Season of 1839. — It does not appear that this place was ever visited 
with the fever till the noted year 1839. Speaking of it, Prof. Carpenter, 
(p. 27), says — "Introduced from New Orleans." Dr. Monette (p. 98), 

* Statistics of Army, p. 258. t Sketches, p. 30. 



252 THE PRINCIPAL DISEASES OF THE 

says — " During the month of September the yellow fever was introduced 
among the merchants, clerks, and laborers, and about fifteen of them died. 
Others from the country contracted the disease." Dr. Monette does not 
tell us of whom he obtained his information. Major Marks, now of Bayou 
Sara, but then of Port Hudson, informs me that the first two patients were 
merchants and brothers, who had not received goods from New Orleans im- 
mediately before, but might have been on board of steamers from the city. 
I know nothing more concerning it. 

Season of 1841. — Dr. Thomas Beaumont, who resided near the village, 
informs me that there were, this year, more than twenty well-marked cases. 
Goods were, as in every other autumn, landed daily, for the interior. On the 
12th of October, before any case had occurred, a gentleman from the neigh- 
borhood rode through the town, and without dismounting, lingered in it about 
three-quarters of an hour. On the night of the 13th he was seized with the 
fever. On the 17th, a citizen of the place was attacked, and on the 19th 
and 20th many others. At the time the fever commenced here it had been 
epidemic for two and a half months in New Orleans, during which boats 
from that city had been stopping and landing goods at the village. In 
fact the epidemic had declined so far, that only 252 admissions had been 
asked at the Charity Hospital, in October, while the number for Septem- 
ber was 642. During this invasion, about twenty persons went from the 
village to the town of Jackson, twelve miles from the river, and two of 
them were taken down with or labored under the fever when they started, 
but the people of Jackson remained unaffected. A man from the neighbor- 
hood, after visiting the place, was seized, and died with black vomit, but 
did not propagate it to his physician or family. 

Season of 1843. — From Dr. B. I learn that the disease reappeared in 
1843, but was rather sporadic. Prof. C. says, the place had daily communi- 
cation with New Orleans. A man from the country contracted the disease, 
but did not communicate it to his family. 

WATERLOO. 

Season of 1839. — Like Port Hudson, "Waterloo seems not to have been 
visited by the fever till this memorable autumn. The following is Dr. 
Monette's account : — * 

" The commercial intercourse between this place and New Orleans was 
uninterrupted; and besides the usual steamboat communication, during the 
epidemic in the city, a number of the French inhabitants, believing they 
possessed a constitutional immunity against the disease, made a visit to 
New Orleans in the midst of the epidemic. After a few days of pleasure 
and dissipation in the city, they returned; and several of these were soon 
attacked with yellow fever, and died. An infected atmosphere was gene- 

* Observations, p. 98. 



INTERIOR VALLEY OP NORTH AMERICA. 253 

rated, and several others, who were not exposed to any other source of in- 
fection, sickened and died. The whole number of deaths at this place was 
about fifteen. I derive this information from D. P. Cain, Esq." 

I know nothing else of this or any other invasion. Waterloo has long 
been a landing-place for the rich settlements of Point Coupee, and its in- 
tercourse with New Orleans was the same, both before and after 1839, as 
in that year. 

BAYOU SARA, AND ST. FRANCISVILLE. 

Season of 1811. — The earliest accounts 1 have been able to obtain of 
the fever at this place (for I shall speak of the towns as one), is from Judge 
Butler, who informs me that it prevailed this year, he himself experiencing 
an attack. It was epidemic that year in New Orleans and Pensacola. 

Season of 1817. — The fever did not prevail this year, but an occurrence 
happened which deserves to be recorded. Prof. Carpenter states it as fol- 
lows : — 

" In 1817, while the yellow fever was epidemic in New Orleans, Phil- 
lips' barge left the city for St. Francisville, and soon began to lose her pas- 
sengers and hands. To replace the latter, new hands were continually 
engaged, who took the disease in succession, so that it was with great diffi- 
culty the voyage was performed; and finally, of the captain, crew, and 
passengers, not one survived. The owner of the barge, Mr. Stoker, who 
resided at St. Francisville, having visited her at the landing, paid the for- 
feit of his life for his imprudence." 

Mr. Remondit, a respectable Creole of Bayou Sara, confirmed this account 
when I was in that place. He stated that Stoker went on board the barge 
to take off the pilot, who was dying of the fever. In thirty-six hours he 
was attacked, and died in four days, with deep yellow skin and black vomit. 
Others went on board, but remained a shorter time, and did not suffer. They 
found the barge excessively foul. There was no spread of the disease. 
These facts show that a river barge may, like a ship, have a yellow fever 
atmosphere, and that persons may die of that disease in autumn in a town 
without communicating it. 

Seasons of 1819 and 1823. — Major Marks and Mr. Bemondit in- 
form me that in each of these years, several travellers and voyagers stopped 
here, sickened with the fever, and died; but did not communicate the 
disease. 

Season of 1827. — Mr. Bemondit and Major Marks assure me that the 
disease prevailed here in 1827. The first case was that of White, a carpenter, 
on the hill in St. Francisville, where the chief population then was. The 
second victim was Monro, who worked on the same building. The mortality 
was very considerable. Disputes arose as to the local cause ; but no one 
suggested its importation. Mr. Long confirms this statement. 

Season of 1829. — The disease seems not to have occurred again till this 



254 THE PRINCIPAL DISEASES OF THE 

year, during which it had been epidemic eleven times in New Orleans. It 
now prevailed in five other places besides New Orleans. Both Dr. Monette 
and Prof. C. are silent respecting this invasion. Dr. J. M. Bell, who had 
lately arrived, experienced an attack. The first case was about the 22d of 
September, in the upper town. The patient had not been to New Orleans, 
but lived in a store that was frequently receiving goods from that city. 

Major Marks and Mr. Bemondit say that the patients in this epidemic 
generally died with cold extremities and without black vomit; but Dr. 
Slaughter, the principal physician, pronounced it yellow fever. Dr. Bell 
says one patient died with black vomit, and his own attack bestowed upon 
him immunity from the disease. 

Season of 1839. — Nine years passed away without another invasion, 
notwithstanding the fever was five times epidemic in New Orleans, and 
this town was a landing-place for goods to supply the country fifty miles 
back !* This year the visitation proved severe and mortal. My principal 
informants are Mr. Ball, the post-master, Dr. Jones, and Dr. M'Kelvey. It 
was entirely confined to the lower town (Bayou Sara), although the inter- 
course, Dr. M'Kelvey informs me, was maintained between the two places. 
One person only had the disease in the upper town, and he came from the 
lower with it. 

The first patient, according to Dr. Jones, was a traveller two or three days 
from Natchez, where the disease was epidemic. He sickened on the 28th 
of August and died on the 1st of September. No other cases immediately 
occurred in the family in which he lodged. The next patient, according 
to Mr. Ball, was Bantee, who had been in New Orleans about a week before. 
He died on the 10th of September. The next was M' Arthur, who had at- 
tended his funeral; and died on the 23d. During his illness several others 
were seized; among them was Harroldson, who lived a mile in the country. 
He attended the funeral and pronounced an address over the grave. He died 
in the midst of his family, but none of them suffered. On the 20th, Dr. 
Jones was called to a woman in the house in which the stranger had died. 
She had yellow fever, but recovered. On the 24th, and 29th, he had two 
cases in two different taverns. Dr. M'Kelvey's first case was that of a mer- 
chant, Collins, taken on the 24th. One of his clerks was seized on the 27th 
and another two or three days afterwards. About the 1st of October, accord- 
ing to Mr. Ball, a merchant, Mr. Baldwin, received goods from New Orleans. 
His two clerks, while yet engaged in opening them, sickened with the fever, 
and both died. 

These facts certainly give strong support to the doctrine of introduction; 
though it is remarkable that the epidemic did not extend into the upper 
town, where, from its absence for nine years, there must have been sub- 
jects for it. It should not be forgotten that this was the season of more 

* Dr. Monette, p. 98. 



INTERIOR VALLEY OF NORTH AMERICA. 255 

extensive geographical prevalence than any other. Dr. Monette (p. 98), 
gives the following account of the origin of this epidemic. 

" When yellow fever became epidemic in New Orleans, many persons came 
to Bayou Sara, and the vicinity, as a retreat from disease ) others arrived 
at intervals subsequently ; and the regular packets, besides the boats in 
the upper trade, continued their trips as usual during the epidemic, until 
many cases of yellow fever were introduced, as at other points. An infected 
district was produced near the steamboat landing, and the disease finally 
spread among the resident population." 

All this is as true of any other year as of this. The cases I have cited 
were scattered over the town. 

Season of 1843. — The epidemic of this year occurred in both lower and 
upper towns. Prof. Carpenter* gives the following account of the origin 
of the fever this season : — 

u Many cases of yellow fever with black vomit occurred, and it was con- 
sidered as of local origin. But a case of yellow fever was taken from 
Baton Rouge to Bayou Sara, and C. Ratliff, Esq., informed me that he saw 
a man from New Orleans who died at the hotel in St. Francisville before 
any of the citizens took the yellow fever, and the man threw up a great 
deal of black matter. The infectious nature of the fever, in these cases, was 
unquestionable, as the connection between the cases was perfectly obvious. " 
The important details of this paragraph led me when in this place to 
make a patient and searching inquiry. 

Lower Town — Bayou Sara. — It appears that the first patient was 
Pierce, a watchmaker, two squares from the river, who died on the 8th of 
August. The second patient was Cosset, a merchant's clerk, on Front Street, 
wlio had been constantly receiving and opening goods. He was attacked on 
the 2d of September and died. The third was Davis, a stranger, who sick- 
ened on the 1st of October and recovered. The fourth was a shoemaker 
from Woodville, where the disease did not prevail, who was attacked soon 
after his arrival on the 2d, and died on the 6th with black vomit. The 
fifth was Rudi, a Creole tailor, who lodged not far from the river, sickened 
on the 2d, and died on the 10th. The sixth was Durell, a stranger, taken 
on the 4th and recovered. The seventh was Johns, a painter, who had 
lived in Baton Rouge j he passed through Bayou Sara, went back into 
the country, remained three or four days, returned sick on the 5th, and died 
on the 9th with black vomit. This was probably one of the cases re- 
ferred to by Prof. Carpenter. The eighth was Portier, who went to Baton 
Rouge on a visit, sickened and died on the 11th. The ninth was his brother, 
who followed to nurse him, and died of the same disease on the 21st. 

Such were the first nine, comprehending nearly all the cases in Bayou 
Sara, as I was able to make them out, by a comparison of dates furnished by 

* Sketches, p. 30. 



256 THE PRINCIPAL DISEASES OF THE 

Dr. Jones, Dr. M'Kelvey, Dr. Gorham, Dr. Bell, and several gentlemen out 
of the profession. No two except the last were of the same family ; they 
were scattered in locality, and it must be admitted that they lend but little 
support to the hypotheses of importation or contagion. It appears in an 
especial manner that the case (7th) from Baton Rouge, referred to by Prof. 
Carpenter, did not introduce the disease. Let us now turn to the 

Upper town — St. Francisville. — As the information which Prof. Car- 
penter had received led him to regard the rise of the fever in this place as 
unquestionably dependent on contagion, and as several persons informed me 
that the man who is mentioned in the extract from his sketches did not die 
of that disease but of mania-a-potu, I was induced to make a patient and careful 
inquiry of Dr. M'Kelvey, Dr. Newman, and many respectable citizens, into 
the whole matter, the results of which I proceed to give:< — 

1. Stafford, the man referred to by him, was not intemperate, but actu- 
ally died of yellow fever, closing with black vomit. He lay in the chamber 
of a coffee-house, and was attended by the keeper and another one, both of 
whom were familiar with the disease, one having had it and the other 
having an insusceptible constitution. He had visited New Orleans, and 
returned on the 5th of September. On the 9th he was taken ill and died 
on the 14th. Dr. Newman saw him when ejecting black vomit a few hours 
before death. 

2. Lurty, had an office two doors from this coffee-house, and three days 
after the death of Stafford visited the bar-room, the smell of which he found 
offensive. On the 11th of October, 21 days afterwards, he sickened with 
yellow fever, but recovered. 

3. Barclay, a merchant, lived one square from the coffee-house, and did 
not visit it. He spent a part of every day at a mill surrounded by swamps, 
in the valley of the Bayou Sara, two miles out of town. Was taken down on 
the 13th of October, and died with black vomit on the 17th. 

4. Johnson, had an office next door to the coffee house, and sat up several 
nights with Lurty • sickened with the fever on the 19th or 20th of October, 
and died at his lodgings in the country, not communicating the disease to 
any of the family. 

5. Dalton, had an office opposite Lurty's residence ; sat up with him, and 
spent much of his time in his room; was taken with the fever on the 20th 
of October, and died on the 25th, with black vomit, at his lodgings in the 
country, not communicating the disease to any of the family. 

6. Ivor, Dalton's partner, occupying the same office with him, and having 
intercourse with him while sick, was seized on the 26th, the day of Dalton's 
funeral, recovered. 

7. Hyatt, had an office one square from Lurty's residence. Assisted in 
nursing Johnson, and was attacked after the 25th of October, on the day 
of Johnson's funeral; died on the 5th day with black vomit. 



INTERIOR VALLEY OF NORTH AMERICA. 257 

8. Dr. M'Kelvey, the physician who attended these patients, was taken 
down on the 2d of November and recovered. 

9. Maynard, had Hyatt in his house, but did not visit him; seized 2d of 
November, but recovered. 

10. Bains,' a friend of Maynard, in the same house through the day, but 
not at night, was seized between the 10th and 15th of November, and died 
on the 8th day of his disease, with black vomit, and had post-mortem 
hemorrhage. 

11. Flower, lived eight miles in the country, spent some time in Dal- 
ton's office after his death, and sat up one night with Bains, the next day 
after which he sickened and died with the fever in the country. 

12. Smith, of the country, visited Johnson during his illness, sickened 
with the fever about the 2d of November, but recovered. 

These were nearly all the cases which occurred. They included the 
sheriff, two officers of the bank, a merchant, and several lawyers, most of 
whom by their pursuits were kept in the upper town, and very few of them 
had much communication with the landing. 

It is worthy of note that here, as in the lower town, all the patients were 
men, and that the disease was uncommonly fatal, seven out of the twelve 
having died. 

On comparing the dates of the cases in the upper and lower towns, we 
find that although the fever began first in the latter, it proceeded nearly 
pari passu in the two places ; apparently indicating an epidemic constitution 
of the atmosphere. 

But what shall we say of the remarkable succession, and apparently deri- 
vative succession, of the cases in the upper town. If the disease really 
had been contagious, would it not have been likely to have acted precisely 
as it did ? If it depended on the general condition of the atmosphere it is 
certainly very remarkable, that the succession of cases should have so exactly 
coincided with the demands of a contagious propagation. But if contagious, 
could Lurty, who visited the coffee-house three days after the burial of Staf- 
ford, have been infected there when he was not taken down till twenty-four 
days afterwards ? Can it be admitted that the remote cause might have lain 
dormant in his system for that length of time ; but then there was no evi- 
dence that Barclay had any communication with either the patient or the 
coffee-house people. If it be asked why, contagion being admitted, a greater 
number were not attacked, the question may be answered by asking why, if 
there were an epidemic constitution of the air, to which all were alike ex- 
posed, these only should have been selected ? Of all the alleged instances of 
contagious propagation which the history of the disease has as yet presented 
us, this appears to me the best made out. 

WOODVILLE. 

Season of 1844. — Although persons from Bayou Sara and other places, 

VOL. II. 17 



258 THE PRINCIPAL DISEASES OF THE 

where yellow fever prevailed, had come to Woodville where they sickened and 
died with black vomit, no spread of the disease had ever followed in that 
town, which was in fact regarded as exempt, till the serious epidemic out- 
break of 1844. From its isolated and interior position, the expectation was, 
I think, very general, that the history of this epidemic would throw much 
light on the origin of yellow fever; while it was still prevailing the Medico- 
Chirurgical Society of Louisiana sent a commission of two of its most respect- 
able members, Drs. De Valetti and Logan, to inquire into the facts of the case. 
Their report* declares the disease to have been yellow fever, considerably 
modified in some of its symptoms. Of the circumstances of its origin they 
found it impracticable to acquire a full and accurate account, as the epi- 
demic was still reigning ; but Drs. Stone and Killpatrick, of Woodville, have 
since published circumstantial histories,f which although conflicting in some 
points, agree on the whole as closely as the narratives of the kind are generally 
found to accord. The former of these gentlemen has presented us with a 
tabular view of the cases which occurred during the first month, which was 
submitted to Dr. Killpatrick and other physicians, and pronounced correct, 
as far as their knowledge extended ; subsequently, however, Dr. Killpatrick, 
as he informs us, gained more exact information on some points, and presents 
it in his paper. I have examined it with care, and endeavored to apply it 
with impartiality to the statement of Dr. Stone. 

Both the gentlemen concur in this, that the Rev. Wm. Thurber, of Texas, 
who on his way passed the first five days of July in the town of Galveston, 
when feeling somewhat indisposed he spent the next three on the island, 
out of town, where he recovered. On the 6th, 7th, and 8th, he heard of 
persons taken sick, but did not learn that they had yellow fever; on the 9th 
he embarked for New Orleans, and arrived at Col. Lewis's, on the south- 
east edge of Woodville, on the 12th. Before retiring, on the night of the 
15th, from having indulged freely in fruit, he was induced to take a dose 
of cathartic pills. About 3 o'clock the next morning he felt ill, and that 
illness proved to be an attack of what both the gentlemen and Dr. Brown, the 
attending physician, agree to regard as yellow fever. On the 1st of August he 
was so well as to leave Woodville. It seems to be agreed on all sides that if 
this case did not introduce the yellow fever, it originated in the town. Let 
us now turn our attention to Dr. Stone's tabular view. 

July 16th. Rev. Mr. Thurber, of Texas, at Col. Lewis's, attended by Dr. 
Brown. Taken at 3 a.m. Recovered. 

Mr. Collins, living 400 yards north, visited Col. Lewis's in the afternoon 
of the day before, and spent half an hour with him in a porch outside of 
the house ; did not see Mr. Thurber. Dr. Killpatrick, who was his physi- 
cian, after approving this date, came to the conclusion that this visit was 
not made the day before, but the afternoon of the day on which Mr. Thur- 

* New Orleans Medical Journal, vol. i. p. 237. 
t Ibid. vol. i. p. 530, vol. ii. p. 49, and p. 196. 



INTERIOR VALLEY OF NORTH AMERICA. 259 

ber was taken, at three in the morning. To my own mind the testimony 
adduced goes to support the first statement. 

But the difference between coming to without entering the house fifteen 
hours before or fifteen hours after Thurber's attack, cannot, I think, be ad- 
mitted to be of much moment. If there was a contagious emanation of such 
virulence in the first day of his attack, as to produce the fever in a single 
day in Collins, who did not enter the house, how could it happen that the 
family, black and white, as well as the nurses, should escape as they did, 
till the 31st of July and 1st of August, more than two weeks afterwards, 
and then have attacks so mild, that no physician was called in. Two ladies, 
moreover, who resided in the family and one who visited them frequently 
were not seized till the 15th, 17th, and 19th of August, by which time more 
than thirty cases had occurred in town, of which two had proved fatal. It 
does not appear that those who watched over Collins took the disease, for no 
mention is made of any such case, except a servant woman, hired out, who 
was said to have visited him, which however was denied. Her case will 
be mentioned presently. Thus if Collins did take the fever from Thurber 
he did not communicate it to the town. 

19th. Mr. Shaw, a stranger, had come from Bayou Sara in company with 
Mr. Thurber, but lodged in a remote chamber of Mr. Thirrell's boarding- 
house, 400 yards off, to the north. Said to have visited Mr. Thurber on 
the first or second days of his illness, but that gentleman, on the 17th, 
the second day, said not. 

22d. A negro child at Lancaster's, 500 yards northwest of Lewis's, and 
not in the neighborhood in which either of the other patients was sick- 
Attended by Dr. Holt. 

24th. A negro child at Col. G-orden's, 200 yards north of Col. Lewis's, 
and not near any of the other patients. Attended by Dr. Martin. 

27th. Maria Ivor, a child, 100 yards north of Collins and Shaw. At- 
tended by Dr. Stone. 

31st. Col. Lewis's children, in the same house with Mr. Thurber. - At- 
tacked two weeks after him. No physician. 

August 1st. Mr. Thurber's two black nurses, servants of Col. Lewis. 
No physician. 

Mrs. G-orden, whose negro child was taken on the 24th of July. Had 
not visited Col. Lewis's. Attended by Dr. Martin. 

A negro woman of Mr. Collins, living with Judge Gildart, in the extreme 
northwest part of the town, but visited her master, it is said, on the fifth 
day of his illness, that is on the 21st of July, and remained for some time 
in his room ; but this is denied by Mrs. Gildart. Attended by Dr. Kill- 
patrick. 

2d. Mrs. Simrall, thirty yards south of Col. Lewis's. Had visited at 
Mr. Lewis's, but not Mr. Thurber's room. Attended by Dr. Stone. 

4th. A second negro child at Mr. Lancaster's. Attended by Dr. Stone. 



260 THE PRINCIPAL DISEASES OP THE 

5th. Mr. Smith, at Thin-ell's boarding-house, where Mr. Shaw sickened 
on the 19th. It is not stated that he had visited Mr. Shaw. Attended 
by Dr. Holt. 

6th. Mrs. Col. Lewis, supposed to have had the yellow fever at Fort 
Adams, in 1839 ; as late as the 23d of July, nine days after Mr. Thurber's 
attack, and two days before he left his room; but had prescribed for her 
servants, taken sick on the 1st of August. No physician. 

7th. Two negroes of Mr. Simrall. One had been at Col. Lewis's fre- 
quently during Mr. Thurber's illness; the other probably not once. At- 
tended by Dr. Stone. 

10th. Mr. E. Keller, returned from the country a week before ; not stated 
whether he visited any one with the fever. Attended by Dr. Brown. 

11th. Mr. Simrall and child ; Mrs. Simrall and two negroes had had the 
fever. Attended by Dr. Stone. 

12th. Mrs. Slade; not stated that she had visited any one of the houses 
in which the fever was ; lived in the vicinity of Thirrell's boarding-house, 
where Mrs. Shaw was taken on the 19th of July. 

Mr. Gillespie, at Col. Lewis's. Attended by Dr. Brown. 

13th. Mr. Posey, in the same neighborhood. Not stated whether he had 
visited any of the sick. 

Mr. John M'Kee, remote; his exposures not stated. 

Dr. Stone's servant, a week from the country. 

Before this last day, says Dr. Stone, cases were occurring in various parts 
of the town in great numbers. The inmates of the jail, however, remained 
unaffected throughout the whole season, but every member of the family 
of the jailer, living in the rooms below the prisoners, was attacked, and he 
himself came near dying. 

I must devote a paragraph to the country : " There were," says Dr. Kill- 
patrick, " numerous instances of persons coming into town and remaining 
a short time, who were very sick in a few days in the country ; some in fact 
who passed through the town with very short delay, were nevertheless at- 
tacked." Dr. Stone says : "A hundred or more cases occurred in various parts 
of the country in persons who visited Woodville during the epidemic." Let 
us inquire into the consequences to the country population of this dispersion 
of cases. 

Moses, a negro man belonging to Mrs. Newell, five miles in the country, 
was frequently in town, and at Mr. Simrall' s during the illness of his wife, 
which commenced on the 2d of August. He died of the fever, on the plan- 
tation, on the 13th of that month. The other negroes continued healthy, 
and between the 7th and 20th of that month, ten of them, on various occa- 
sions, had been sent into town. The others were taken while in town, and 
passed through the fever at Simrall's. On the 28th of August, two weeks 
after the death of Moses, the fever appeared among the negroes who had 
not been (or had not been known to be) in town, and the first six cases 



INTERIOR VALLEY OF NORTH AMERICA. 261 

were of that class ; it then fell upon the other class, and affected both indis- 
criminately. The mother of Moses, however, who nursed him, was the last 
taken down, nearly nine weeks after his death. 

Judge Walker, six miles in the country, contracted the fever in Wood- 
ville, and died at home on the 11th of September. ' One of his servants was 
in Woodville on the 11th of August, and had the fever on the 5th of Octo- 
ber; another who was in the town on the 5th of September, and also nursed 
his master, was attacked on the 20th of August. 

Morris lived two miles from Woodville. Several of his servants had been 
in town and suffered from the fever, which was limited to them. 

Holt lived ten miles from town. Four of his servants who had been there 
experienced attacks three and four weeks afterwards. 

On Burrass's plantation, late in the fall, there was a case in an individual 
believed not to have been in town. 

On Trask's plantation, seven miles out, a negro was attacked on the 4th 
of September, who it was positively asserted had not been in Woodville 
since the preceding December. Of course there may have been error in 
both these cases, as the negroes might have gone and returned in the 
night. 

Many persons left Woodville for Natchez and Bayou Sara, during the 
epidemic ; of whom not a few sickened by the way, and after reaching 
Natchez, but did not communicate the disease. 

On the plantations of Brandon and Keary, fifteen miles from Woodville, 
there were fevers of a single long paroxysm, unlike the ordinary intermit- 
tents of the season, and others were observed on different farms in the 
country. Dr. Powell, of Pincheyville, saw many cases of this kind, and 
among them two cases contracted in Woodville, and could observe no differ- 
ence in the symptoms. These and the generality of the cases of the fever over 
the country, as in the town, did not admit of the use of the sulphate of qui- 
nine, the specific in ordinary years. 

Such are the most important facts bearing on the origin of this epidemic, 
as furnished by its historians. Let us by their aid attempt to answer this 
question. 

Did Thurber, from Texas, give the fever to Woodville, or did it give the 
disease to him. 

1. We have already seen that the attempt to fix on Collins and Shaw as 
the persons through whom he spread it, has been unsuccessful ; for, in the 
first place, the former could not have contracted the disease from him, and 
did not communicate it ; and in the second place, if the latter did contract 
the fever from him, which may be questioned, he did not propagate it. 

2. Those who might have been infected from him, if his disease were 
communicable, were not affected before, but simultaneously with or after 
several others. 



262 THE PRINCIPAL DISEASES OP THE 

3. Many who visited and nursed others, as Shaw and Collins, were not 
taken down till after the fever had become generally prevalent. 

4. As Thurber was sick on the edge of the town, if the disease could spread 
from him there seems to be no reason why it should not have spread in the 
country from those who took it by visiting Woodville, and certainly none 
why it should not have been introduced into Bayou Sara and Natchez. 

5. Yellow fever generally begins in July and increases till September, 
when it prevails most, and ceases in November. This epidemic followed the 
same course, and the arrival of Mr. Thurber and Mr. Shaw on the 12th of 
that month might have been an accidental coincidence. That, as strangers 
to that atmosphere, they would have been highly susceptible, will be granted 
by the whole profession, and that they had been there long enough to be 
acted upon by it, if a poison floated in it, will be admitted by those who 
insist that Collins had the disease from Thurber in fifteen hours after a 
visit to the outside of the house, and that Shaw had the fever in one or two 
days after an alleged visit to the patient. 

6. It appears that the negroes of Mrs. Newell, eight miles in the country, 
had the fever without having visited Woodville, but it also appears that 
over the country generally, there was an epidemic constitution similar to 
that over the town. 

On the whole then, I am driven to the conclusion, from the facts which 
have as yet been made public, that Thurber did not introduce the disease, 
and that if he did, there are other facts which have not yet been brought to 
light. If it be asked, what then was the origin of the fever, I answer that this 
is a totally distinct question, on which I do not propose, at this time, at least, 
to enter. 

TOWN OF FORT ADAMS. 

Season of 1839. — Notwithstanding so many places, both below and 
above this place, had been so often affected with yellow fever, it does not 
appear to have occurred here till the great epidemic season of 1839. Ac- 
cording to Dr. Monette it was introduced in the same way as into the 
other towns below ; I suppose by the arrival of boats from New Orleans, 
and the landing of passengers and goods for the interior; operations which 
had taken place annually for many years before. They may have intro- 
duced the fever this year and not previously ; but to say they did is to 
assume what the facts should prove : these he has not given us. It is 
worthy of remark that this was then, as it had long been, a principal land- 
ing-place for the town of Woodville, from which we have just passed, and 
which seems to have been as free from the fever in 1839, as Fort Adams 
was in 18-14. Such facts involve the aetiology of the disease in great 
mystery. 

NATCHEZ. 

Seasons antecedent to 1817 — During the period now under considera- 



INTERIOR VALLEY OF NORTH AMERICA. 263 

tion, yellow fever was epidemic seven times in New Orleans, without occur- 
ring, as far as can be now known, in the town of Natchez. Dr. Lattimore 
came to the place in 1800, when he could not learn that the disease had 
ever prevailed. Nevertheless, it has been supposed that Mr. Elliott saw it 
there in the summer of 1797;* but a careful examination of what he wrote, 
has convinced me that the disease was but the endemic autumnal fever of the 
Southwest. At various times, however, the physicians of Natchez saw cases 
of yellow fever from New Orleans, of which the autumn of 1804 furnished 
the most memorable examples. Dr. Perleef informs us that he was assured 
that a barge arrived with nearly all its crew, amounting to thirty, ill with 
yellow fever. They were landed and brought into town, where all the sick 
except two died, none of the attendants or residents of the place being at- 
tacked. This account was confirmed to me, in 1844, by Dr. Lattimore, who 
was at the time a physician of Natchez. During this period of time the 
internal condition of the town appears to have been nearly the same as it 
was in the 

Season of 1817. — This year the fever prevailed as an epidemic. As to 
the topographical condition of the place, the only difference between this 
and the preceding years, seems to have been that of considerable grading of 
the streets, commenced, as Dr. Lattimore informed me, in this or the lat- 
ter part of the preceding year, whereby much new earth was exposed to 
the action of the sun and rains. The latter were more equably distri- 
buted through the three summer months than usual, and the aggregate 
12-33 inches was less than the average of nine years, of which it was one, 
by -84 of an inch. It might in fact be called a dry summer rather than a wet 
one. As to heat, the mean temperature, 77-76°, was only -24 above the 
mean of the preceding seven summers, while it was less than three of them, 
and nearly 3°, below that of the summer of 1816. 

Such was the condition of the town as far as Dr. Perlee, the historian of 
this epidemic, could make it out on emigrating thither subsequently. J As 
early as August, occasional cases of yellow fever were seen in town, but 
where they were contracted, Dr. Monette§ could not learn. Dr. Perlee 
has not mentioned these cases, but as Dr. Monette is a believer in importa- 
tion, we may presume that he has satisfied himself of their occurrence. In 
the beginning of September, the steamboat Washington arrived at the land- 
ing from New Orleans, where the fever was then epidemic, with persons on 
board ill with yellow fever, some of' whom were landed. Several young 
men of the town went on board, who were all taken sick soon after and 
died. The disease spread rapidly over the city and displayed a character of 
great malignity. It was suddenly checked by a severe frost on the 9th of 
November. 

Dr. Monette and Prof. Carpenter have attributed this epidemic to the 

♦Journal, p. 288. f Phila. Jour. vol. iii. p. 5. t Observations, p. 62. 

\ Phila. Jour. vol. iii. p. 17. Observations by Geo. Sargent, attached to Dr. Perlee's paper. 



264 THE PRINCIPAL DISEASES OF THE 

Washington, but as cases had occurred in August, and she arrived early in 
September, when in all places where it occurs yellow fever is rapidly 
spreading, we may suppose the coincidence accidental, but it is universally 
admitted that the atmosphere of a boat or ship may be like that of a city 
or the portion of a city whose atmosphere will produce the disease, and 
therefore the atmosphere of Natchez, and of the boat, were both contami- 
nated with the same poison, but the latter more deeply than the former. 
Thus on going on board the young men got their systems additionally im- 
pressed by the remote cause. The true question is whether the atmosphere 
of the boat could have produced its like in the atmosphere of the town, not 
whether it could poison those who came on board ; and also, whether those 
who were thus poisoned, could poison others. If they could, they would 
spread the disease. If they could not, they could not spread the disease. 

It does not appear that cases of the fever in town were traced up to cases 
generated on the boat; and therefore its importation was not made out even 
admitting that it was imported. I mean that as it existed in the city before 
the boat arrived, and it was not shown that the arrival was the cause of the 
subsequent increase, a case of importation is not on logical rules made out. 
Cases of the fever were imported — and a quantity of the cause was im- 
ported, which produced other cases in those who exposed themselves to it, 
which is all that we know. The data necessary to any other conclusion are 
wanting. The alarm of the young men on discovering the unhealthy con- 
dition of the boat, may have acted as an exciting cause to the disease; to 
which, as it had already begun, they, in common with the other inhabitants 
of Natchez, were predisposed. The next year was exempt from the fever; 
and was distinguished as being the first year of quarantine. The fever pre- 
vailed this year in New Orleans. 

Season of 1819. — The summer of this year had a mean temperature of 
78*66°, which was 1-03° higher than the mean of the nine preceding years, 
but it was less by 2-25° than the mean of three years just before, when the 
fever did not prevail — less by 3-03° than one of those years. It is impos- 
sible, then, to admit the agency of great comparative heat in the production 
of this epidemic. But the rains of this summer were great — more copious 
than those of the preceding nine, except 1812. They amounted to 23-43 
inches; or 10-26 inches more than the mean of the preceding nine years; 
they came within 1-56 inch of the year 1812, and rose above 1813, 3-04 
inches; finally, they exceeded the rains of 1817, 11*11 inches — that is were 
nearly double. Shall we then admit the influence of these copious rains in 
the production of the fever of this year ? We cannot, because in the sum- 
mer of 1813 nearly as much fell, in 1812 a greater quantity, and in neither 
year was there any fever; still further, the fever prevailed in 1817, when 
the quantity of rain was little more than half that of 1819. It is impossi- 
ble to grant that great dryness, and great moisture in the same locality, so 



INTERIOR VALLEY OF NORTH AMERICA. 265 

near the same time, can produce the same effects. It must be admitted, 
however, that if the rains fell at any time so copiously as to produce an 
inundation, sinister effects upon health might result from that cause, and 
this Dr. Perlee tells us was the case in July, when the quantity was nearly 
eleven inches, which inundated hundreds of acres of land in the valley of 
Catharine's Creek, drowned many animals, and left a covering of slime which 
emitted an offensive smell. But in 1812, there fell in that month 9-11 
inches of rain, and we may presume a similar overflow occurred, yet no 
yellow fever followed ; however, the temperature of August this year was 
79°, while that of August, 1812, was only 76°. Shall we ascribe the pro- 
duction of the fever to the additional 3° of heat? Finally, in 1817 there 
was an epidemic, in the absence of great rain and also of great heat, as that 
of the month of August was only 77°. 

As soon as it was known that the fever had begun in New Orleans this 
year, the authorities of New Orleans established a quarantine and cordon 
sanitaire, about the middle of July, which Dr. Tooley tells me were rigidly 
enforced; notwithstanding which the epidemic began on the 1st day of 
September with several cases at the upper end of Main Street, near a pond. 
On the 2d, Dr. Perlee saw four others, who worked in one shop in the 
same locality ; on the 4th, a man died with black vomit in the Natchez 
coffee-house. On the 4th also, Dr. Tooley saw a case near the east end 
of the town, remote from the river. The Board of Health now announced 
the existence of the fever, and the greater part of the population fled to 
the country. It does not appear that any boat having yellow fever patients 
on board landed at the wharf, but the Alabama, with cases of that kind, 
stopped on the 28th of August at the village of Yidalia, opposite to Nat- 
chez. According to Dr. Perlee's statement, which is not questioned by Dr. 
Monette, no one came from her to the city. Many of the refugees took 
lodgings in Washington, but as I was assured when there, none of its in- 
habitants had the fever. This epidemic, which was very mortal, did not 
finally cease till the 1st of December. 

Dr. Monette speaks of this epidemic in language which implies that it 
was imported, and Prof. Carpenter, quoting him as authority, says, " Intro- 
duced from New Orleans." Still Dr. Tooley, who was then in its midst, 
assures me that the contagionists were silent, and that no one even sug- 
gested its importation. This autumn the fever prevailed in many places. 

The years 1820, '21, and '22 were exempt; yet Dr. Monette is persuaded 
that sporadic cases occurred from opening goods from New Orleans. Why 
it did not spread he does not explain. In 1820 and 1822 it prevailed in 
that city, and in the latter of these years at many other places. In -the 
two years in which it was in New Orleans, the quarantine at Natchez was 
enforced ; and might have been regarded as the cause of its absence from 
Natchez, but for its invasion the next year, while the quarantine was still 
in existence. 



266 THE PRINCIPAL DISEASES OF THE 

Season of 1823. — The epidemic of this year was the most fatal that 
has ever visited Natchez. Its historians are Drs. Tooley,* Merrill,f and 
Dr. Cartwright.t 

1. As to the weather before the setting in of the epidemic, Dr. Tooley, 
long the meteorologist of that city, informs us that the spring months were 
moderate as to wet and heat and presented nothing unusual. From the 
middle of July to the middle of August the weather was dry and sultry; 
the mean heat was 87°. From the last week in July to the 24th of August, 
the winds varied from southwest to west, blowing briskly in the day and 
moderately at night, with heavy dews. According to Dr. Merrill, the months 
of April, May, and June brought forth many deluging rains. About the 
1st of July the weather became suddenly very dry and warm, the thermo- 
meter ranging from 80° to 93°; which weather continued with little varia- 
tion to the 25th of August, beyond which we need not extend the account, 
as the fever had already set in. From Dr. Cartwright we learn that the 
atmosphere of spring and early summer was unusually damp. 

2. An extraordinary flood in the Mississippi inundated the wide bottom 
lands of Louisiana, opposite and below Natchez j but as the fever did not 
occur, and such floods are common there, it is unnecessary to say more of 
that. 

3. Dr. Merrill ascribes the fever to the grading of the streets, which, as we 
have seen, was begun in 1816, but does not tell us that it had been going on 
in the winter or spring preceding this epidemic. 

4. Dr. Tooley dwells on the deposit of carcasses on a terrace of the bluff 
below the city, to which reference has been already made ; but this had been 
practised for years before, and there is no evidence that the quantity this 
year was greater than usual. 

5. Dr. Cartwright, after recognising this infected spot, speaks also of a 
large pile of putrid oysters in the western edge of the town ; and of a house 
in the southern part which contained a considerable part of a flat-boat load of 
bacon, pickled pork, and fish, nearly all of which in the month of July were 
in a state of putrefaction. Dr. Tooley recognises the same fact, Dr. Mer- 
rill admits it, and the city council have certified to the general accuracy of 
Dr. Cartwright's statement; and still Dr. Monette§ was assured by Col. 
Fleming Wood, the alleged proprietor of the bacon, that the information on 
that subject was entirely erroneous, and that no such lot of bacon was in 
the city ; such is the discrepancy of yellow fever history. 

6. All the historians of this epidemic, as well as the sexton, whose regis- 
ter I examined, concur in this, that the first cases of the fever appeared in 
houses remote from the river, and that the people of Natchez-under-the-hill 
remained free from it for a fortnight after several well-marked cases had 

* History of the Yellow Fever as it appeared in Natchez in 1823. 

f Phil. Jour. Med. and Phys. Sci. vol. ix. p. 225. J Med. Record, vol. ix. p. 1. 

§ Observations, p. 66. 



INTERIOR VALLEY OF NORTH AMERICA. 267 

occurred in the upper-town. In short there seems to have been no suggestion 
of its having been brought from New Orleans. It appears, moreover, that 
there was this year a quarantine against boats from that city, but Dr. Monette 
(p. 69) declares it was not well observed ; nevertheless he does not attempt 
to trace up the epidemic to its violation. 

7. Dr. Cartwright has given us the following important observation, 
which is however by implication partially contradicted by Dr. Merrill. "In 
June and July the common bilious fever of the country prevailed in the city, 
but there were but few deaths. At length the progress of the bilious fever 
was suddenly arrested, and nothing but the Lichen tropicus or prickly heat 
disturbed the health of the citizens. About this time the cats took a dis- 
temper, of which many died. From the 1st to the 9th of August, excepting 
one child, there was not a death in the city." 

8. It is worthy of remembrance that during the season of this mortal 
visitation no other town in the valley of the Mississippi experienced an attack ; 
and although Prof. Carpenter speaks of the disease as having been introduced 
from New Orleans, it will be seen by reference to its history in that city for 
1823, that it was scarcely if at all sporadic there, and that of the two cases 
introduced into the Charity Hospital one was two, and the other four weeks 
after the epidemic of Natchez commenced. 

We come now to the outbreak of the epidemic, but instead of giving the 
first case cited by Dr. Cartwright and Dr. Merrill, the verity of history re- 
quires that I should follow a suggestion of Dr. Tooley, who says of a person 
who died on the 24th of July, that the attending physician reported the 
disease as pneumonia, but that from various circumstances and symptoms, 
there is reason to believe that this lady died of sporadic yellow fever. Her 
name, as Dr. Tooley and the sexton informed me, was Howard. After 
the sexton, who was well acquainted with yellow fever corpses, saw the 
body, he told Dr. Provan, the physician, that the patient must have had 
yellow fever, on which that gentleman remarked, "If you talk so you will 
frighten the people away." Now this lady, who lived near the house in which 
was the putrid bacon, around which the first cases reported by Dr. Cart- 
wright occurred, had been on a visit to the Eastern States, and returning by 
sea, touched, it was said, at Havana. How long she had been back before 
her attack, neither the sexton nor Dr. M'Pheters, nor any others with whom 
I conversed, could after the lapse of more than twenty years make out, but the 
sexton said it was not a long period. We do not know what length of time 
may elapse after the system has become impressed by the cause of yellow 
fever, before the disease shows itself; but its history at Woodville presents 
cases of the disease in the country three and four weeks after visiting the 
town ; and intermittent fever, from which we may borrow an analogy, often 
appears for the first time, several months after exposure to its remote cause. 
Is it not possible then that this lady returned home with the semina of the 
disease in her system, from landing at Havana, or from the atmosphere of 



268 THE PRINCIPAL DISEASES OP THE 

the ship ? If this were the fact it would not prove that the other cases which 
occurred almost immediately afterwards in the same neighborhood were pro- 
duced by hers ; it would not establish the contagiouness of yellow fever, nor 
the importation of fomites in her baggage; but admitting the transmissi- 
bility of the disease, it might explain perhaps the outbreak of this epidemic. 

We come now to Dr. Cartwright and Dr. Tooley's statement of the first 
cases. 

On the 9th of August Mrs. Wynn died, in the very house in which was 
the spoiled bacon; on the 11th, Mrs. Van Campen died in the same house, 
both with black vomit ; on the same day a young lady, Miss Blake, who had 
frequently visited the house, died in a distant part of the city ; on the same 
day Judge M' Caleb, from the country, dined there, sickened on the 15th, 
and died on the 18th; on the 13th, Mr. Sill, who lived hard by, fell a victim 
to the same disease; on the 16th, Mr. M'Guire, living at Mr. Sill's, died; 
and on the 22d, Mrs. M'Guire; finally, by this time four or five others in 
the same neighborhood had become the victims of the disease, while other 
parts of the city remained exempt. The disease now began to manifest 
itself over the city generally, but was most prevalent in the southern por- 
tions where it first appeared. 

In fact it seemed to extend into the edge of the adjoining country to the 
south almost as fast as it advanced north through the city ; so that ulti- 
mately, according to Dr. Cartwright, there were few families within a mile 
that escaped it. One of these patients declared that he had not been in 
town for some months. 

As the disease began to prevail, a great part of the population fled to the 
country, where many of them sickened and died, but Dr. Cartwright did not 
hear of a single case of propagation of the disease. 

A large portion of the fugitives sought an asylum in the town of Wash- 
ington, six miles to the east, where they sickened and died in large numbers ; 
but not a citizen of that place, according to Dr. Cartwright, took the disease, 
except he had visited Natchez. When I was in Washington I assured myself, 
by a rigid inquiry, of the truth of this remarkable fact, the more remarkable 
because the town was crowded to overflowing. But the case was different 
at a quasi village, on the road to Washington and five miles from Natchez, 
called Coonsville. There happened to be at this spot some unoccupied 
cabins, and a number of temporary sheds were put up. Into these about 
sixty persons of the poorer class were crowded, bringing with them all 
their movables. Many of these, according to Dr. Monette,* sickened and 
died of the fever ; and in addition, five persons who visited the place and 
had not, it was said, been exposed in any other way, sickened and died. 
When in Washington, a respectable lady, the daughter of the proprietor of 
the Coonsville plantation, confirmed this statement, and added to the num- 
ber reported by Dr. Monette. Another reputable lady bore witness to the 

* Observations, p. 65. 



INTERIOR VALLEY OF NORTH AMERICA. 269 

truth of this statement; Dr. Branch of Washington testifies to the same. 
Dr. Cartwright is as silent respecting it as Dr. Monette is concerning the 
immunity of the people of Washington, which Dr. Cartwright presents so 
prominently. One believes in the foreign, the other in the domestic origin 
of the fever. 

There was no fever in 1824 ; it was however moderately epidemic in New 
Orleans. The quarantine was still continued, and enforced in the following 
year, though not, as Dr. Monette informs us, in the manner that was neces- 
sary to render it efficient. The advocates of local origin are bound to 
admit that the quarantine may exist in name and form, but not in fact. 

Season of 1825. — This year there were great rains in March and April, 
but they diminished to September, when the amount was little more than 
one inch. The whole quantity in June, July, August, and September, 
according to Dr. Merrill, was only 12-74 inches, amounting to only half the 
quantity which fell in 1819, when the fever was likewise epidemic. The 
mean temperature of July, August, and September of this year, three miles 
in the country, according to the same writer was 78-66°, or about one degree 
above the mean common in the city j according to Dr. Cartwright, in the 
afternoon (for his table does not admit of a comparison of the morning observa- 
tions) : it was, for July, 91-50° in 1824; and for the same month in 1825, 86°; 
but in August of the former, it was only 87°, while for the latter it was 91 ° ; 
for September, 81*75° in one year, and 83° in the other. Thus, while July 
was hotter in 1824 than in 1825, by 4-5°, August was cooler by 4°, and 
September by 1-75°. The heat and dryness of August and September, in 
fact, were beyond; the temperature, according to Dr. Merrill, was 78-66°, or 
1° above the usual average ; it also appears that the heat of July and 
August was equal; but according to Dr. Cartwright' s table, August was 5° 
hotter than July. It is difficult for history to reconcile these discrepancies. 

The three historians of this epidemic have assigned three causes for it, 
each having full confidence in his theory of its origin. They all agree as 
to the place and time of the first cases, — at the landing in " Natchez-under- 
tne-hill" — where the first patient died on the 21st of August, with black vomit, 
after a few days' illness. Other cases rapidly succeeded, till ten had died 
out of a very limited population, but the town above remained unaffected, 
according to Drs. Merrill and Cartwright, for the next six weeks. 

Occurring at the wharves in a mercantile house, and the yellow fever 
prevailing in New Orleans at the time, Dr. Monette, rejecting the causes 
assigned by the two others as harmless, is convinced, that, notwithstanding the 
quarantine, it was imported from that city. He does not, however, desig- 
nate any particular boat. Dr. Merrill informs us that the first wharf had 
been constructed in the preceding spring, and that a great deal of loose earth 
had been dug from the adjoining bluff, and used in forming it ; and to the 
exhalations from this, under the action of sun and rain, he ascribed the 
production of the disease; declaring the theory of nuisances " wholly unsa- 



270 THE PRINCIPAL DISEASES OP THE 

tisfactory," and asserting that no new accumulations had taken place. He 
does not even refer to importation. Dr. Cartwright, treating that theory and 
the fresh earth theory of Dr. Merrill with equal silence, directs our atten- 
tion to the nuisances accumulated on and about the landing, as sufficient to 
account for the epidemic which began in their midst. These consisted 
chiefly of spoiled porter, sour pork, putrid sauerkraut, fish, oysters, a 
boat of rotten corn, and the slime of the river beach upon the subsidence of 
the waters. 

As to the cases which subsequently occurred in the town, Dr. Monette 
derives them from the patients who escaped, or were taken from the landing, 
but cites no special examples ; while Dr. Cartwright and Dr. Merrill concur in 
declaring that none could be cited. The former of these gentlemen found 
the origin of the disease in the continued exhalations from the earth thrown 
up and spread abroad in grading the streets, and levelling the lots between 
them. Lastly, the latter gentleman has pointed out three special localities 
of filth within the city, and one without its limits, where he assures us 
nearly all the cases on the hill occurred. It does not appear, however, that 
they had been created immediately before the epidemic, but had existed in 
the previous year, when the disease was absent, and in the year before that, 
when, although epidemic, it did not particularly affect those localities. Thus, 
each of these theories is embarrassed by the fact that the fever had been 
absent, when, according to its requirements, it should have been epidemic. 

On the 30th and 31st of August, Dr. M. informs us, although the fever 
had not yet originated in the upper town, a large portion of its inhabitants 
fled to the country and to the villages. Two died at Coonsville, one at 
Kingston, and one at Fort Adams; but according to Dr. C. there was no 
spread of the disease at either place. But the chief asylum was 

WASHINGTON. 

It has been already stated that this village had been the resort of the 
people of Natchez during the epidemics of 1817, 1819, and 1823, many 
of whom had died in the midst of its hospitable families, without, in any 
instance, communicating the disease. Nevertheless yellow fever was not 
entirely unknown at Washington, for Dr. Branch assured me that in 1821, 
when Natchez was entirely exempt, he saw several cases, some of which were 
attended with hemorrhage and black vomit j and Dr. Monette* declares that 
he has " occasionally seen sporadic cases of yellow fever in the vicinity of 
Washington" when there was no epidemic in Natchez. 

This year, 1825, presented a sad reverse of 1817, 1819, and 1823, for 
although free from the fever till after the people of Natchez crowded into it, to 
actual overflowing, as some lived in tents, the disease soon became mortally 
epidemic among the resident population, affecting them, indeed, so much 
more than it did the refugees from Natchez, that many of the latter at 
length returned to the city. This outbreak of the disease under circum- 

*Essay, p. 70. 



INTERIOR VALLEY OF NORTH AMERICA. 271 

stances apparently the same as those of the three preceding years when it 
did not occur, cannot but be regarded as a remarkable phenomenon. Only 
two years before, while this place, although crowded, remained exempt, 
Coonsville, but a mile from it, and under the same topographical circum- 
stances, was afflicted; but now, in turn, remained exempt, although a place 
of resort not less than Washington. If the want of susceptible subjects at 
Coonsville this year will explain the immunity, a similar explanation will 
not apply to the people of Washington two years before. Dr. Monette, 
whose residence is in this town, and Dr. Cartwright, who followed the fugitives 
to it, are the historians of this extraordinary epidemic, and both very justly 
concur in the opinion that it could not be ascribed to anything in the 
topographical condition of the place, for it is in fact an open village of 
about one hundred houses, on high, dry, and rolling land. Nor can it be 
ascribed to a disturbed state of the soil from excavations, for none had been 
made. Its historians, however, were not slow in satisfying themselves as to 
its origin, but fixed on very different sources. 

1. According to Dr. Monette, in the previous epidemics of Natchez, Wash- 
ington " had been the retreat of the merchants, mechanics, and others who 
wished to continue their trade with the country," and who had of course 
brought their goods with them; they had, moreover, not retreated from 
Natchez till after the fever had become epidemic, but this year they left it 
before a single case had occurred away from the river, and in their goods 
and household effects brought, as Dr. Monette conceives, the fomites which 
infected the people of Washington as well as the patients who secreted 
contagion ; still further he informs us that several bales of blankets, direct 
from New Orleans, where the fever was epidemic, were opened, and that the 
first citizens of Washington who were attacked were persons engaged in 
opening these blankets. Of these victims the one most spoken of was Mrs. 
Caruthers, but she died on the 27th of September, in the week previous to 
which eleven inhabitants of Washington had died of the fever in various 
parts of the village, and consequently she might have contracted the disease 
from the same cause with them. Indeed Dr. Monette informs us that by 
the 18th it was epidemic; and Dr. Branch, who was her physician, assured 
me that at the time she was taken it was prevailing throughout the vil- 
lage. Such is his theory of its origin. 

Now the question may be asked, why a state of things identical with this 
did not produce the fever in 1817, 1819, or 1823 ? If an alleged cause failed 
three times out of four to produce the effect, are we at liberty to admit its 
reality in the fourth? As to direct propagation of the disease from citizens 
of Natchez, who sickened with it, to the people of Washington, I was told 
by its oldest physician, Dr. Branch, and many intelligent citizens, that they 
had not known a single case; and indeed Dr. Monette does not cite any; 
but appears to rely on fomites ; but whence came the fomites if not from the 
bodies of those laboring under the fever, emanating as morbid secretions ? 



272 THE PRINCIPAL DISEASES OF THE 

but the people of Natchez when they fled to Washington had not yet been 
affected with the fever, for it had not appeared except at the landing. 

2. Dr. Cartwright, from personal observation and inquiry on the spot at 
the time of the fever, found an adequate cause in two nuisances, — a ravine 
and a grocery, which were contiguous to each other and in the centre of the 
village. He does not seem, however, to lay much stress on the former, 
which is indeed a gentle declivity terminating in a gully of such rapid 
descent that nuisances cannot accumulate in it, and which merely serves as 
a drain for the rains that fall on two squares of the village, and never has 
any other water flowing in it. The grocery contained the stock in trade of 
a citizen of Natchez-under-the-hill. At what time he transferred himself 
to the centre of Washington does not appear, but it was, as Dr. Cartwright 
informs us, in the latter part of summer. This grocery was said to contain 
about 2000 pounds of putrescent bacon, and two or three barrels of salted 
mackerel in the same condition. Before the fever broke out the bacon was 
removed, but the mackerel remained ; and the lot in the rear of the store 
was made the receptacle of offal from Mississippi fish, which the grocer was 
in the habit of receiving. These, according to Dr. Cartwright, were the 
sources of the fever in Washington. As bearing on this point he has ag- 
gregated a mass of testimony concerning the stench emitted from this house, 
which is too long for insertion here. But as to its extent and intensity 
there are conflicting statements, for in 1844, Dr. Branch, whose office was 
opposite the grocery, and Mr. Babb and Mr. Newman assured me, that they 
had not perceived it, and did not even hear it spoken of at the time when 
the fever was prevalent. If moreover it were so putrescent as to generate 
a fever, why was it kept for sale, and how could it have been disposed of 
in a single night, as Dr. Cartwright was told it was, in such manner that it was 
never afterwards seen ? That some portions of it might have spoiled, and 
not the whole, must be admitted. Dr. Cartwright has also given a long cata- 
logue of the first and subsequent cases with their localities, showing that 
the disease prevailed most among those most exposed to this alleged source. 
Admitting the general correctness of this statement, two obvious remarks 
may be made upon it. First, cases of the disease occurred in distant parts 
of the village nearly as soon as at the centre, and that too in persons who 
had not been in the neighborhood of the grocery, while others who had, 
escaped. Thus the police officer who went to the store to look after the 
bacon escaped, but his wife, as she informed me, who lived more than a 
square from it, and did not visit it, was seized in four days after the first 
patient, that is, on the 19th. In her conversation with me she could recol- 
lect fifteen of her acquaintances, scattered over the village, who were taken 
down within one day of herself; a recollection which coincides with Dr. 
Cartwright' s statement, that " between the 18th and 25th the disease sprung 
up in various parts of the town and its suburbs." Now, as Dr. Cartwright 



INTERIOR VALLEY OP NORTH AMERICA. 273 

states the first case to have occurred on the 15th, we see it was less than a 
week before all parts of the town were affected. 

2. The number occurring around it was not greater in proportion to the 
density of population than in the other parts of the village. They were 
numerous because the people among whom they occurred were numerous. 

3. Dr. Cartwright informs us, that it was a few days before the fever com- 
menced (on the 15th of September), that the police officer went to examine 
into the fact of there being putrid bacon in the grocery, and found it was 
gone. The alleged cause of the disease was removed, then, even before 
the fever broke out on the 15th; and the grocer, Dr. Cartwright informs us, 
returned to Natchez before the end of the month. Now between the 20th, 
when the first death (Miss Patrick, in the west suburb of the village) oc- 
curred (according to the statement of Col. Marshalk), and the end of the 
month, there were seventeen deaths ; in the ensuing month, October, there 
were seventeen more, and in November, up to the middle, eight. Can it be 
admitted that these individuals were all empoisoned previously to the 15th 
of September, and that the fever was developed in their systems in the pro- 
gressive manner indicated by this chronology ? Such a rise and reign are 
in exact accordance with the general history of the disease, and not con- 
formable, it seems to me, with the simultaneous impress of the system by a 
noxious exhalation, withdrawn from the whole at the same time. 

I am compelled, therefore, to conclude, that the origin of the fever in 
Washington is not shown to be from this nuisance. 

If I have dwelt on this subject it is because the outbreak of the fever in 
such a detached village seemed to afford extraordinary facilities for arriving 
at a knowledge of its cause. Natchez and "Washington were the only places 
above New Orleans visited this year. 

In conclusion I may add that since this epidemic Washington has not been 
visited by the fever, although it has been three times prevalent in Natchez. 
Thus of seven visitations in that city one only has extended to Washington. 

Let us now return to Natchez. 

Season or 1829. — From 1825 to 1829 Natchez experienced no visitation. 
In the latter year the fever reappeared. Its history I believe has never been 
published. Dr. Monette informs us that it was the mildest ever known in 
the city. He says nothing of its origin. Prof. Carpenter marks it as intro- 
duced from New Orleans. 

Although I can say nothing on the history of this epidemic in Natchez, 
I am enabled to give, from Dr. Merrill, an interesting narrative of the 

Fever in 1829 on a Plantation. — Two miles east of Natchez was the 
cotton plantation of Mr. Robert Moore, whose residence was on the brow 
of a hill west of the valley of St. Catherine's Creek. In spring or summer, 
before ploughing his crop, he removed a heap of putrid cotton-seeds, and 
the surface of the ground saturated with the rains which had passed through 
it, and scattered the whole over his fields. Piles of cotton-seeds when pu- 

VOL. II. 18 



274 THE PRINCIPAL DISEASES OF THE 

trefving. Dr. Merrill informs me. send forth an intolerable stench. Mr. 
Moore was in the habit of visiting Xatehez. where yellow fever was mildly 
epidemic. On the 4th or 5th of September he was taken unwell. Dr. Mer- 
rill saw him on the 6th. and on the 9th he died with black vomit. On his first 
visit, the 6th, one or two days after Mr. Moore began to feel unwell. Dr. Mer- 
rill prescribed for five other members of the family, children and servants, 
who had fever; and on the 7th the number had increased to eight; on the 
9th it was augmented to ten at the dwelling-house, aud fourteen in the " quar- 
ter;" the overseer and thirteen negroes. The overseer was taken on the 
7th. two or three days after the owner of the plantation. On the 10th he 
prescribed for four children, the overseer, and thirty negroes; on the 11th 
for three additional negroes : on the 12th foi two children and eig:. 
negroes ; on the loth for fifteen negroes (the children having been removed); 
on the 14th for ten negroes; and on the 15th for eight negroes. On the 
16th, he had as new patients a young man, Mitchell, who had gone there 
to assist in nursing the sick, and Webster, a schoolmaster, who had been 
living there; on the 21st, prescribed for them and several negroes; both 
the white men died with black vomit : on the 24th, prescribed for eight 
patients, one of whom was a nephew of the deceased planter, who had come 
there to assist the family and was taken down that day ; on the 25th and 
26th. had five patients ; on the 27th. the nephew died with black vomit — 
numbers of patients the same ; on the 28th and 29th. number the same. 
One or two of the negroes only died. On the 29th of October, a lady who 
was housekeeper in the family and had been to Cincinnati on a visit, re- 
turned ; she slept one night in the house and then went to another planta- 
tion ; a few days afterwards she sickened and died of black vomit. All 
the fatal cases were well marked as yellow fever. Mr. Moore's family had 
always been so healthy that he was accustomed to speak of his residence as 
the Montpellier of the Mississippi. 

That this was yellow fever it seems impossible to doubt. Mr. Moore 
had no wife at the time and there were but few white persons to be affected. 
To the few it was uncommonly fatal. Its greater mildness among the 
negroes is characteristic of that disease. At first view it would seem that 
Mr. Moore had introduced the disease from Xatehez, and that we have before 
us a conclusive example of contagion; but if reliance can be placed on the 
dates of the narrative, and Dr. Merrill gave them to me from a record made 
at the time, we find the attack of the overseer and the field negroes quartered 
away from the dwelling-house, to be almost as early as that of the master, 
and seem required to regard the whole as depending on a local cause. Still, 
we do not know but that those who really had yellow fever had been in 
Xatchez : which must have been the case with the lady who was landed 
there, and that the negroes had the ordinary fever of autumn; but Dr. Mer- 
rill did not regard it as of that kind, but he looked upon the whole as one 
disease. 



INTERIOR VALLEY OF NORTH AMERICA. 275 

After the great epidemic of 1823, the quarantine, as Dr. Tooley informed 
me, was abandoned ; and, for a considerable part of that time, according to 
Dr. Monette's* essay, cases of yellow fever were taken from New Orleans 
steamboats, through the town, to the hospital ; still no case occurred in the 
city from 1829 to 1837, although the fever was epidemic in New Orleans 
four times. 

Season of 1837. — This year there was a severe epidemic. According to 
Dr. Monette,-j- the weather for several weeks before the middle of August 
was rainy, but afterwards became dry, though showers occasionally fell. 
His account of the temperature is imperfect, but it appears to have been 
higher than that of most autumns. The disease began about the 8th of Sep- 
tember; its rise was gradual, and the chief mortality was in October. By 
the 9th of November the fever was declared to be gone. J Dr. Monette has 
given us a minute account of the parts of the city most affected, which were 
the southwestern j the northeastern half, he states, could hardly be said to 
have been visited by it. 

Its chief prevalence was in the neighborhood of the bayous and gullies 
which cut up the portion of the city most desolated by it. The very first 
cases occurred more than a mile from the landing; and if they arose from 
the introduction of the sick or of fomites from boats, it was known at 
the time when Dr. Monette wrote, in the following year. On the whole, if 
we are to credit this gentleman, the fever originated on the spot. Dr. Pol- 
lard, in the newspaper just quoted, declared the same thing. It is worthy 
of record that the inhabitants fled this year as in the preceding to Washing- 
ton. The newspaper of the 27th of October says, "Washington is quite 
a stirring village just now; its inhabitants have with open arms received 
into their hospitable dwellings many of our convalescent or flying citizens. 
Two of our large mercantile houses have opened assortments of goods there." 
Now according to Dr. Monette, § the dispersion of the people, even up to the 
middle of October, when the epidemic had existed five weeks and was at its 
height, had been gradual and slow. Yet not a case occurred among the 
people of Washington, although twelve years had elapsed from the epi- 
demic of 1825, and of course there must have been many susceptible persons 
among them. How then could the coming into that town of the inhabi- 
tants of Natchez, before a single case had occurred in the city proper, have 
been the cause of that epidemic ? If it were transmitted in 1825, why was 
it not transmitted, under circumstances much more favorable to that mode 
of propagation, in 1837. Prof. Carpenter has marked this epidemic as in- 
troduced from New Orleans. The disease was either sporadic or epidemic in 
several other places this year. The next season, 1838, the disease was 
sporadic in New Orleans and Mobile, and did not occur anywhere else in 
the Valley of the Mississippi. 

Season of 1839. — We come now to the memorable season to which we 

* Essay, p. 75. f Ibid. p. 75-80. $ Mississippi Free Trader (newspaper). § Essay, p. 75. 



276 THE PRINCIPAL DISEASES OF THE 

have made such repeated reference. According to the books of the sexton, 
the first death from the fever this year was on the 31st of August ; the 
patient a laborer at the landing, who was taken to the hospital. On the 
20th of that month, as Dr. Davis informs me, a woman from New Orleans 
was landed and carried to the hospital, where she died of the same fever. 
On the 10th of September, the sexton's books report four deaths at the 
hospital with the same fever, all taken at the wharf; on the 9th, Dr. Davis 
had a patient there with the same disease, who recovered. On the 11th, 
the newspapers announced a few cases at the landing. On the 18th, three 
or four cases, with black vomit, at the landing, are announced, and the alarm 
increasing. By the 22 d, as Dr. Davis informs me, the disease had spread 
over the city. On the 7th of October, according to the newspapers, the 
inhabitants of Natchez were effectually scattered, and had taken refuge in 
the country, the town of Washington, and the village of Selsertown. The 
epidemic was extremely fatal to those who remained behind. On the 10th, 
it is stated that the authorities of Washington had prohibited the introduc- 
tion from Natchez of anything but provisions. Dr. Monette, however, 
states that this prohibition took effect on the 18th of September, three 
weeks before, and that yellow fever patients were also excluded ; to which 
he refers the immunity of the people of Washington, notwithstanding an 
equal degree of exemption in 1817, 1819, 1823, 1829, and 1837, when no 
such prohibitions existed; nevertheless eight of the refugees were taken down 
in the midst of the crowded population; enough, we might suppose, to gene- 
rate contagion, if that disease produces it. On the 9th, 10th, and 11th 
of November, high winds, followed by frosts, put an end to the disease. The 
inhabitants of Washington and Selsertown remained exempt. 

We have in this epidemic a distinct and undisputed river-shore origin. 
The filth of the landing and the beach, exposed to the sun by the subsidence 
of the river, and the steamboats daily arriving from New Orleans and other 
towns below, where the disease was epidemic, were here also combined. To 
which of them, or whether to both the disease should be ascribed, must 
forever, as far as facts collected at the time are relied upon, remain an un- 
decided question. Twelve years had passed away since the fever had begun 
in that locality, and the same state of things had existed. Why did the 
disease now occur for the first time during these twelve years ? 

Seasons of 1840 to 1845, inclusive. — The epidemic of 1839 was 
followed by so total an absence of the fever over the Valley of the Missis- 
sippi and on the northern coast of the Grulf, that but two cases were re- 
corded as such at the Charity Hospital of New Orleans, and none elsewhere. 
In the winter of this year, in consequence of the quay-origin of the fever 
of the preceding year, quarantine regulations of a more stringent kind than 
formerly existed were re-established, and were in operation in the year 
1841. In that year the fever was epidemic in New Orleans, Vicksburg, and 
some other places. In 1842, in New Orleans and two other places; none in 



INTERIOR VALLEY OF NORTH AMERICA. 277 

Natchez. Id 1843, extensively prevalent, and Natchez said to be exempt; 
but Dr. Lysle has given me the names of six patients in Natchez-under-the- 
hill, who, he says, had the characteristic symptoms of yellow fever. They 
generally recovered, but one died with black vomit. They occurred early 
in October. A number of other patients experienced mild attacks. In 
1844 the disease was only sporadic in New Orleans ; in 1845, scarcely a case, 
and none either year in Natchez. In the former of theseryears, as we have 
already related, many fugitives from Woodville came to Natchez, and some 
sickened with the disease, but it did not spread. 

Since the year 1817, yellow fever has been epidemic nineteen times in 
New Orleans ; six times in Natchez, and once in Washington. If Washington 
received it that time from Natchez, what prevented her receiving it the 
other five times ? And again, if Natchez received it six times from New 
Orleans, what prevented its reaching her the other thirteen times? These 
questions remain to be answered. Meanwhile they stand in the way of the 
theory of importation, and strengthen the conclusion to which I am carried 
by the history of each epidemic, that the recorded and recollected facts con- 
cerning it do not establish its importation. It seems, in fact, to have been 
of local origin, although the assigned local causes of most of the epidemics 
are far from being proved to have been such. 

RODNEY. 

This village is situated on the left bank of the Mississippi, forty-five 
miles above Natchez, in north latitude 31° 30'. Its site is the upper and 
northern extremity of a bottom which widens to the south, and becomes 
lower so as to be overflowed when the river is high ; but the site of the town 
is too elevated for such an inundation. Near the final extremity of the 
bottom a ravine enters from the east, and the torrent which flows along it 
after showers and in rainy weather, when it reaches the plain, turns directly 
to the north, and discharges its waters into a deep bayou or gully, the water 
of which rises and falls with the river ; immediately below this bayou the 
plain is wide enough for a square, and here the town was commenced in 
the year 1823. As to the rest, there is a road or street up the ravine, along 
which there are houses ; and down the river, a street with houses on each 
side, very near the river, to the west, and equally near the bluff to the 
east. The steamboat landing is a short distance from the square, down this 
street. In addition to the commercial and social intercourse between New 
Orleans and this place, on its own account, goods are landed here for the 
interior, and these operations have been going on from its first settlement, 
but, of course, increasing with its growth and the increasing population of 
the country in its rear. Up to the season I am about to mention, although 
by no means exempt from the ordinary intermittent and remittent fevers of 
the country, it had experienced no invasion of yellow fever. 

Season or 1843. — In the month of May, 1844, at a meeting of the 



278 THE PRINCIPAL DISEASES OF THE 

Medico-Chirurgical Society in New Orleans, I bad the pleasure of listening to 
a history of the epidemic of the preceding autumn, by Drs. Williams and 
Andrews, who were entirely convinced of its importation, and I went to 
Rodney in the expectation of finding a well-marked and conclusive case of 
that kind. Wishing to review all their facts, I felt it my duty, with them 
and the other medical gentlemen and several intelligent citizens, to make 
a patient and rigid inquiry, the results of which I shall now state, borrowing 
from their papers such facts as may be necessary.* 

It appears that when copious rains swell the torrent which descends from 
the hills through the ravine of which I have spoken, a part of the water, 
instead of flowing into the bayou, continues down the street to the river, 
and on its way overflows the square on which the first houses of the town 
were built. In addition to this, much filth and damaged produce are often 
thrown upon the beach, and into the shallow water in front of this square, 
from flat-boats. The latter, especially, was the case in 1836 and 1837, when 
that part of the beach emitted an intolerable stench in July and August. 
The ordinary fevers of those years were unusually violent and fatal, but did 
not put on the form of the epidemic of 1843. At that time the population 
was double what it was in the latter period, and at all times the village was 
as filthy as in the epidemic year. During the spring and summer of that 
year, the inhabitants of the square and whole upper part of the town were 
very much annoyed by the overflowings of the hill torrents, most of which, 
however, soon percolated into the soil or evaporated, so that at the outbreak 
of the epidemic it had nearly disappeared.-)- About the middle of June, the 
ensuing year, I made a careful examination of this square, which is nearly 
covered with houses, for many are built on its interior. I found them all 
of wood, without cellars or foundation stones, their sills lying directly on 
the ground, and consequently all that falls through the floors remains there. 
One of them, standing on Magnolia Street, west side of the square, was taken 
down on the first day of the preceding autumn. Its foundations, like those 
of all the rest, except the newest, were in a state of decay, and an offensive 
odor exhaled from the spot where it stood, indeed, before it was torn down. 
The ground, as far as I could examine, was wet underneath most of the 
houses, and water could be seen below some. The house in which the fever 
commenced was Mrs. Logan's, in the interior of the square, though not far 
from its southern side, immediately in the rear of the demolished house and 
to its leeward, as it respects the winds of summer. 

August 26th. — Dr. Andrews resides by the side of the demolished house. 
On this day his daughter was seized suddenly with fever, accompanied with 
costiveness, vomiting, and a flushed face. It did not assume, with distinct- 
ness, the intermittent character. At length she sunk into a listless condi- 
tion, without fever, had a slight spasm, and died without black vomit or 

* N. O. Med. Journal, No. 1. p. 35. f Ibid. p. 36. 



INTERIOR VALLEY OF NORTH AMERICA. 279 

hemorrhage. But this cannot be affirmed to have depended on the same cause 
with those which followed. 

September 6. — Young Logan, whose residence I have indicated, seized 
this day, died with black vomit on the 12th. His attack was six days 
after the removal of the house of which I have spoken. He was fifteen 
years old, and going to school up the ravine, away from the river at the 
time. I could learn nothing of his visiting steamboats or stores where 
goods were opening, but Drs. Williams and Andrews state that a gentle- 
man saw him on board of one which had yellow fever patients a few days 
before, which is highly probable, as it was the practice of all who had curi- 
osity or business to go on board every boat that arrived. 

7th. Mr. Brown, a merchant on the same square, contiguous to the house 
that was demolished and very near to Mrs. Logan, was attacked, but reco- 
vered. 

9th. Mrs. Keed, living between the patients just mentioned, visited Logan, 
recovered. 

10th. Mr. Bicks, in the same house with Mr. Brown, died with black 
vomit on the 15th. 

11th. A brother of Logan, in the last stages of consumption, lodging in 
an adjoining chamber, died on the 13th, the day after the first. 

13th. Mrs. Logan seized. 

15th. Mr. Logan, her son, taken down. 

19th. Mrs. Martin, Mrs. Logan's daughter, living on the west side of the 
same square, at a short distance, and having constant intercourse with the 
family, taken down, died on the 28th. One of the servants experienced an 
attack. Four of the family died. 

After this date many persons living on or around the square, and others 
scattered over the village, but in the habit of visiting the sick on the square, 
were seized, and among the rest, Dr. Savage, by which the South lost one 
of its ablest physicians. 

Now the opinion of Drs. Williams and Andrews is, that young Logan con- 
tracted the disease by going on board some steamboat, and communicated it 
to the family and they to others. This may be the truth, but the facts do 
not warrant the conclusion, inasmuch as the whole family, including himself 
and all those who have been mentioned, were equally exposed to a nuisance 
which it is alleged produces yellow fever, and if that allegation be true, 
then the family might have fallen victims to the disease in the very order 
in which they did. When two assigned causes for a phenomenon coexist, 
either, a priori, might produce it; while neither is known to have done so, 
it is altogether arbitrary to ascribe it to one of them. The advocates of 
local origin have the same right to ascribe it to nuisances, and the late Dr. 
Savage and Dr. New asserted that right. But correct logic denies a demon- 
stration to both parties, — in other words the history of these cases decides 
nothing relative to the origin of the disease. 



280 THE PRINCIPAL DISEASES OP THE 

Drs. Williams and Andrews, however, found another source of imported 
infection, and do in fact derive the epidemic from an additional magazine 
of fomites. The second case, that of Mr. Brown, who sickened on the 7th, 
the day after the first patient, and Mr. Ricks, who was seized on the 10th, 
four days after the first, are ascribed by them to fomites attached to goods 
imported into a mercantile house nearly adjoining Mrs. Logan's, which goods 
they assisted in opening. These goods were received on the 3d of Sep- 
tember, and consisted of four boxes of American prints, put up in Philadel- 
phia, and sent via New Orleans. I was told, furthermore, that six bales of 
damaged blankets had been opened by these gentlemen and others in the 
same store, and emitted an offensive smell ; but the bill of lading was dated 
on the 12th, in New Orleans, and the goods could not have been received 
before the 14th, seven days after Mr. Brown was attacked, four days 
after the attack of Mr. Ricks, and only one day before he died. Thus if 
Brown and Ricks contracted the disease from fomites, they must have ad- 
hered to the boxed-up calicoes which had only been lodged in a warehouse 
in New Orleans on their way from Philadelphia. Several others besides 
the house which received these goods, received supplies (as they do every 
year) of various articles, including blankets, from the 10th to the 14th of 
September, but there was no evidence of their introducing the fever, which 
had, indeed, distinctly shown itself before those dates. Now the remarks 
made on the other branch of this theory are applicable to this. As Brown 
and Ricks lived on the square, and breathed the same atmosphere with the 
Logan family, they were liable to the disease if it could originate there. 
Thus, without denying the transmissibility of the fever, or asserting its local 
origin, I am compelled to dissent from the conclusion of Drs. Andrews and 
Williams, and say that the origin of this, the only epidemic of Rodney, for 
the twenty years it had existed, during which the fever, in New Orleans, 
had been sporadic six times and epidemic fourteen times, with regular com- 
munication between the two places, is not established. Indeed, the theory 
of nuisances derives rather more support from this history than that of 
fomites and contagion, both of which must be resorted to in this case to sus- 
tain the doctrine of importation, for every year added something to the foul- 
ness of the square on which the fever broke out, by the joint decay of the 
wooden houses and the accumulation of offal matters beneath them, and in the 
adjoining bayou; but every year did not add to the importation of goods, 
for, according to Drs. Williams and Andrews, the population (and conse- 
quently importations) of the town were twice as great in 1836 as in 1843 
when the disease occurred. Finally, the fever this year began in New 
Orleans on the 5th of July and was epidemic in August. So that it 
prevailed there for two months before its appearance in Rodney, during 
the whole of which period steamboats were stopping and discharging pas- 
sengers and merchandise every day. 

In conclusion, I may state that Mr. John A. Watkins, the oldest resident 



INTERIOR V ALLEY OF NORTH AMERICA. 281 

of Rodney, informed me that persons had died there of the fever contracted 
in New Orleans, in 1827, '28, '29, and '35 without communicating it. 

YICKSBURG. 

Yicksburg was begun, as we have seen, in 1819. In 1827 Dr. Ander- 
son, now of St. Louis, saw a few sporadic cases, as he regarded them, of the 
fever ; and again a greater number in 1837, in both of which years it was 
extensively prevalent in the Yalley of the Mississippi. Dr. Hicks also saw 
four cases in the latter, which ended in black vomit. One of the patients 
had come from Natchez — the rest were of the town. One of Dr. Anderson's 
patients, in 1827, was lately from the State of Illinois. In 1838 there was 
none. In 1839 it was according to Dr. Harper sporadic. He saw cases 
with black vomit. Dr. Gill reported a patient as dying of yellow fever, and 
the town council altered it to bilious fever. Dr. Hicks saw quite a number 
of cases along the river-shore, in the neighborhood of the landing, among 
the poor and dissipated. All the houses were filthy underneath and wet 
till July. The margin of the shore had been raised by shavings, various 
kinds of decomposable matter, and dirt. Many patients from Natchez with 
yellow fever were put off here. This was the great epidemic year of the 
Valley of the Mississippi. In 1840 no cases were noted. 

Season of 1811. — This year, the 22d from the settlement of the town, 
was the first in which the disease assumed an epidemic character. The 
observations relative to its onset, which I was enabled to collect, are not 
very numerous or satisfactory. That it chiefly invaded the southern part 
of the city, on the hills, where the population was relatively sparse, was 
stated by all with wtiom I conversed. 

Dr. Hicks on the 20th of August had his first case. The patient, Collins, 
had come from a levee twenty miles up the river. His second patient, 
Owen, about the 1st of September, had been three weeks on a plantation up 
the river. Was taken, as he reached home, with what was called the Yazoo 
or swamp fever; got so well as to sit up, relapsed, and died on the 12th 
with black vomit. On the same day Dr. H. was called to a Dutch girl, and 
three or four others in the same house (locality not mentioned). She died 
with black vomit. The disease now began to prevail extensively. 

Dr. Harper's first patient was a woman, on the hill. Date not given. 
His second was on the 2d day of September, also on the hill, and soon after 
two others sickened in the same house. 

Dr. Anderson's first case was an Irish laborer; his second, Judge Martin, 
living back on the hill, taken immediately after his return from an excur- 
sion into the Yazoo swamp ; third case, on the hill; fourth, the sheriff and 
his family, on the hill, in the centre of the town. None of these patients 
had visited steamboats. 

Dr. Balfour's first patient was on the 8th of September, second on the 
9th, both on the hill. A large number of cases occurred in a house half- 



282 THE PRINCIPAL DISEASES OF THE 

way up the hill from the river, which was crowded with poor Irish. In the 
neighborhood of this house, at three o'clock p. M. of the 4th of July, 1844, 
my thermometer, buried an inch beneath the surface of the ground, rose 
from 90°, the atmospheric temperature, to 116°. 

Dr. Emanuel thought the transition from ordinary autumnal to yellow 
fever was gradual. He spent much time around the destitute sick, in giving 
them assistance, and often breathed a most offensive atmosphere ; but did 
not contract the fever. He observed that nurses and others did not often 
have it. 

The negro population according to Dr. Hicks, remained unaffected till 
near the end of October, when it became prevalent and fatal among them. 
It ceased about the 9th of November, after a second severe frost. 

Previously to and at the time of the outbreak of this fever, steamboats 
from New Orleans, where the fever was epidemic, were constantly arriving, 
and landing goods and passengers, as had been the practice from the first 
settlement of the town. The localities and histories of the first cases seem 
to have convinced all the medical gentlemen of the place, that they were 
indigenous. Nobody, I was assured, attempted to show importation. Prof. 
Carpenter is silent respecting this epidemic. 

The season of 1842 was said to be free from the disease, but Dr. Balfour 
saw a well-marked case with black vomit in a young woman. 

Season of 1843. — Vicksburg participated in the extensive epidemic 
prevalence of this year. Dr. Anderson observed that the ordinary autum- 
nal fever assumed many of the symptoms of yellow fever. Dr. Emanuel 
did not hear of any cases with black vomit. Dr. Hicks, had such cases but 
they were not numerous. Dr. Harper saw a few ; they were scattered over 
the city and did not seem to be connected with the wharves or steamboats. 
On the whole this was a mild and limited epidemic. 

Prof. Carpenter notes this epidemic as probably introduced from New 
Orleans. Dr. Monette remarks that Natchez was this year screened by the 
revival of her quarantine, and Vicksburg invaded from the want of such 
protection. It may be asked what defended her in the preceding twenty- 
two years, during which the fever was epidemic in New Orleans fifteen 
times ? 

In 1844 and '45, Vicksburg remained free from the disease ; the narrative 
of the invasions suggest the following remarks. 

1. The commerce of New Orleans with Vicksburg steamboats has always 
been considerable, as it is a chief landing-place for the interior, including 
Jackson, the capital of the state; and as the population was greater in 1836 
than it was in 1841, the importation of goods for city consumption must 
have been greater. 2. The great excavation which has been described com- 
menced in 1836, and was continued to 1839. Now in 1837 it was distinctly 
sporadic; in 1839 it reappeared; and in 1841 it was fatally epidemic. 3. 
As we have seen, much of the removed earth was deposited opposite the 



INTERIOR VALLEY OF NORTH AMERICA. 283 

lower part of the city, on the edge of the narrow plain, and built upon, the 
boat-landing being at the same time brought down from that part which 
was first built. This transfer, and the general decline of population, with 
consequent vacated and foul houses, as already described, took place not 
long before the epidemic of 1841. Thus of the various alleged causes of 
yellow fever, one, the commercial, had long existed; the other two, fresh earth 
and nuisances, came into existence just before or about the time of the ap- 
pearance of the fever. 

MEMPHIS. 

Dr. Wyatt Christian came to Memphis in the year 1826. Had seen im- 
ported cases of yellow fever in different years down to 1844, when I con- 
versed with him. Many of them proved fatal in the hotels and boarding- 
houses, but he never saw the fever propagated in a single instance. In 
1842, the steamer Louisiana stopped at the wharf for twenty-four hours, 
having sixteen yellow fever patients on board ; and the people of Memphis 
visited her throughout the whole time ; but no one contracted the fever. 

Season of 1828. — In this year yellow fever was epidemic in Memphis, 
the history of which, as communicated to me by Dr. Christian, I shall now 
proceed to record. At that time Memphis was an inconsiderable village, 
with scarcely any population in its rear, and so little commerce or social 
intercourse with New Orleans that steamboats seldom stopped, and a fort- 
night frequently elapsed without a single landing. For some time before 
the fever broke out, no steamer had stopped. The fever that year was epi- 
demic in New Orleans and sporadic in Mobile; but no case was landed at 
Memphis. Autumnal remittent and intermittent fevers this year were 
more severe than Dr. Christian has ever seen them since. 

Case 1. The first case of yellow fever occurred on the 8th of September, 
in a laboring man, who had not yet spent an autumn in Memphis. He 
worked about the flat-boat landing and on the boats, and lodged between 
the bluff and the Mississippi, just below the mouth of the Wolf River. On 
the fourth day he died with black vomit. 

2. His wife was taken on the next day after him and died on the sixth 
day with the same symptoms. 

3 and 4. Their two children were attacked in the same manner with the 
parents, immediately after the mother; but both recovered. 

5 and 6. About ten or twelve days after the first of these attacks, two 
men, one a hatter and the other a gardener, who lodged in a house under 
the bluff, about 100 yards from the other, were taken with the same disease, 
one dying with the other without black vomit. 

7, 8, 9, 10, and 11. We must now turn to another part of the town. A 
quarter of a mile from the river and from the patients just enumerated, on 
the upper terrace, was a brick yard, at which there were six operatives, five 
white and one black. While the woman, case No. 2, was still alive, that 



284 THE PRINCIPAL DISEASES OP THE 

is, before the 15th, one of these white operatives was seized with the same 
fever ; in three clays two others, and on the following the remaining two ; 
the negro only escaping. Two of these patients died with black vomit, 
the other three recovered. It was not known that these individuals had 
had any communication with the house of the patient No. 1. 

Before the last of these patients had died, the fever had begun to show 
itself in the village, containing from 250 to 300 inhabitants, every part of 
which it invaded. The whole number of cases was about forty, of which 
fully oue-half proved fatal ; no negro was attacked. The duration of the 
epidemic was about six weeks, or until near the 1st of November. 

Symptoms. — As it might be doubted whether this was really yellow fever, 
I desired Dr. Christian to give me a detail of its more prominent symptoms, 
which were as follows : The attack was generally sudden, the individual 
being in good health up to the time of it. He had slight chills and flushes 
of heat, with great sense of weariness. The hot stage which succeeded 
was intense and lasted from twenty-four to thirty-six hours, when it ceased 
and did not return ; but the patient, when recovery did not take place, re- 
mained with a pulse beating between eighty and ninety, restless, thirsty, 
destitute of appetite, with a cool skin, and a tongue exhibiting rather a red 
and flabby appearance. In this condition he would lie two or three days, not 
sleeping any, and having his secretion of urine entirely suppressed. His 
stomach would then become irritable, and at length he would begin to 
vomit. The matter ejected, at first of a greenish or bluish tint, soon showed 
dark-colored flakes, and ended in a black color which left an indelible stain 
on the floor. While lying in the state which preceded the black vomit, he- 
morrhage from the gums, sometimes from the nose, and in one case from the 
bowels, occurred. But one recovery took place after black vomit. 

There can be no doubt that this was genuine yellow fever. Dr. Hose and 
Dr. Russell both pronounced it so, and Dr. Christian referred me to the 
latter, who had emigrated to North Alabama, for a verification of his own 
history. Ud fortunately, I deferred doing so till Dr. Russell died. Dr. 
Hose had previously died. All who know Dr. Christian, as one of the most 
respectable physicians and citizens of Memphis, will confide in both his 
veracity and correctness of observation. Unless in the absence of all oppos- 
ing testimony we impugn them, we are, I think, almost compelled to admit 
that this was an instance of purely indigenous epidemic yellow fever. 

Of local causes, Dr. Christian's mind was turned to two : — 

1. The foul state of the flat-boat landing, immediately below the mouth 
of Wolf River, where the first cases occurred. 

2. In 1827, the year before the epidemic, three cotton-gins were erected 
in Memphis, and worked throughout the following autumn and winter. 
One of them stood between fifty and one hundred yards from the house 
where the first cases occurred ; the other two about the same distance from 
the brickyard where the other group of early cases was. As this was in 



INTERIOR VALLEY OF NORTH AMERICA. 285 

the early periods of cotton-planting in West Tennessee, gins were not yet 
numerous in the country, and a great quantity of picked cotton was brought 
to these establishments. None of the seeds separated during the winter 
were removed, and Dr. Christian estimates that the piles around the diffe- 
rent gin-houses must have amounted to several thousand bushels. Exposed 
to the rains of the succeeding spring, and sun of the following summer, these 
accumulations passed into a state of putrefaction, and sent forth a stench of an 
acid quality, which, evening and morning, could be perceived at least half a 
mile. This odor began to be perceptible about the 1st of September, and 
on the 1st October the piles were burned up. One evening during the pre- 
valence of the fever, a lady walked with her husband into the neighborhood 
of the gin near the river, and found the air very offensive. On returning 
home, she was seized with a chill, and had a serious attack of the prevailing 
fever, but recovered. 

Whatever importance may be attached to this statement, the reader cannot 
fail to observe its coincidence with that given on the authority of Dr. Mer- 
rill concerning the fever on the plantation of Mr. Robert Moore, near 
Natchez. 

gallipolis, o. 

" Dr. Miller, of New York, in his excellent essay on yellow fever, refers to 
the journal of a voyage down the Ohio, in 1796, by Mr. A. Ellicott. This 
judicious observer was a witness, at Gallipolis, inhabited by some miserable 
French families, to the disease, which raged violently, the fatal cases being 
generally attended with the symptom of black vomit. " The fever could 
not," he says, " have been taken there from the Atlantic States, as my 
boat was the first that descended the river after the fall of the water in the 
spring. Neither could it have been taken from New Orleans, as there is 
no communication up the river at that season of the year. [This was prior 
to the era of steamboats.] Moreover, the distance is so great, that a boat 
would not have time to ascend the river, after the disorder appeared that year 
in New Orleans, before the winter would set in." [Extracted by the 
Editor.]* 

new design, mo. 

" In 1797, the disease appeared at New Design, fifteen miles from the 
Mississippi and twenty from St. Louis, and carried off more than one-fourth 
of the inhabitants, although no person during the preceding twelve months 
bad come to this village from any place at which the malady prevailed. 
As these facts are attested by Dr. Watkins, who had seen the disease in 
Philadelphia, and as an identity of disease supposes an identity of cause, it 
is shown indisputably that fevers with the pathognomonic features of typhus 
icterodes, do occur in positions which forbid the assumption of importation." 
[Extracted by the Editor.]! 

* Army Statistics, p. 9. f Ibid. 



286 THE PRINCIPAL DISEASES OF THE 

FORT SMITH, ARK. 

Fort Smith* is seated on the left bank of the Arkansas River, near the 
mouth of the tributary called Poteau. " Lakes and marshes abound in 
every direction, some being subject to be inundated from the Arkansas and 
Poteau Rivers. "f 

Yellow Fever in # 1823. — In the work just quoted, p. 41, we have the 
following report from Assistant-Surgeon Finley : — 

" Fort Smith, October 15, 1823. 

" Sir : — From the accompanying report of the quarter ending the 30th 
September, you will observe that the mortality of this post has been un- 
usually and alarmingly great. Prior to the 5th of September, our diseases 
did not assume a character calculated to excite any anxiety, but were such as 
we anticipated in this season and climate. About the period just named, the 
fever became more rife, and manifested a violent grade of action. When 
first attacked, the patient complained of slight chilliness, which was soon 
succeeded by fever, general pains, most severe in the head and loins, and 
excessive irritability of the stomach, attended with continued vomiting 
and excruciating pain in the same region. Although the application of a 
blister invariably relieved the pain, it had not the effect of arresting the 
vomiting, which only ceased with death. The matter discharged from the 
stomach was black, and had the appearance of clotted blood. The pulse 
was quick and soft, and the eyes were red and painful. After the first 
twelve or eighteen hours, delirium ensued ; the tongue became black, rough, 
and dry ; the thirst, owing to the irritability of the stomach, was unquench- 
able ; and finally, coma and convulsions announced the approach of death." 
[Extracted by the Editor.] 

In New Orleans, Mobile, or Natchez, a fever of this character would un- 
doubtedly be pronounced yellow fever. If it were, it must have been in- 
digenous, as steamboats, in 1823, scarcely ever went to that point, and could 
not have done it in July and August. 



CHAPTER VI. 

^ETIOLOGICAL DEDUCTIONS FROM THE FACTS PRESENTED IN THE 
FOREGOING HISTORIES. 

Let us now proceed to ascertain the bearings of the facts which have been 
set forth, on the origin and spread of yellow fever. 

Passing by the vexed and difficult inquiry, whether the yellow fever of 
Havana originated there, or was introduced from abroad, we may speak and 

* North latitude 35° 22'. t Army Statistics, p. 229. 



INTERIOR VALLEY OE NORTH AMERICA. 287 

treat of it as a disease of that city ; seeing that although it is not exten- 
sively prevalent every summer, it is never absent, and thus, if not a native, 
is a naturalized endemic. In reference to the first case that ever occurred 
in that city, it may be said that if the cause was generated there, the subse- 
quent prevalence of the disease has no doubt depended on the continual 
generation of the same cause. 

If the disease was imported, we may assume, with equal confidence, that 
the introduction and continuance of the fever have depended on one of two 
causes, — either a contagious emanation from the bodies of the sick, in per- 
petual succession, or a peculiar fermentative power in the portion of em- 
poisoned air originally imported, whereby it transformed that of Havana 
into its like, and has ever since kept up the disease. 

But the same views are not applicable to Xew Orleans, where a colder 
winter might destroy the cause of an imported disease, which would not 
reappear till it was reintroduced. Hence the fever may prevail annually 
in Havana, although originally an exotic, but be frequently extinguished in 
New Orleans, and require to be imported anew. 

Our first inquiry relates to contagion. In the prosecution of this, the 
rules of logic require the exclusion of all cases in which the disease is said 
to have been contracted by going on board of a ship or boat where there 
were yellow fever patients, or by visiting a patient in a town affected with 
the fever when it is epidemic, for the individual in these cases is exposed 
to the same atmosphere which may have produced the fever in the sick, and 
it cannot be told whether he contracted the fever from them, or from enter- 
ing the same localities which had occasioned it in them. We must also, for 
the same reason, exclude the cited instances of epidemic fever soon after the 
arrival of a ship or boat, because it may have brought a portion of the at- 
mosphere from the sickly port whence it sailed, or may have arrived at the 
moment when the disease was about to appear from local causes. Thus re- 
stricted, the number of facts going to show the propagation of yellow fever 
by contagion is surprisingly small, and most of them far from being un- 
questionable. 

1. When speaking of the introduction of the yellow fever into Opelousas, 
in 1837 and 1842, we gave an account from Prof. Carpenter's book of the 
apparent successive propagation of the disease from two strangers who arrived 
there from Xew Orleans and sickened of the fever. It will be recollected 
that steamboats do not reach this town. But it must be remembered that 
in the former of these years the disease was extensively prevalent : in the 
latter, however, it was limited to Xew Orleans and Mobile (see p. 213). 

2. When the body of Dr. Smith, of Plaquemines, was taken to Xew Iberia 
(see that article), it was said there was no fever in the village, but that 
nearly all who visited the church in which the corpse was deposited or at- 
tended the funeral, were soon afterwards seized with the fever. This was in 
1839, when the disease was more extensively prevalent than in any other year. 



288 THE PRINCIPAL DISEASES OF THE 

3. Under the head of St. Francisville there are details which show an 
apparent propagation of the fever from .one person to another; but the 
fever that year was extensively epidemic, and previously to the occurrence 
of the second link in that chain of cases, it was prevailing in the adjoining- 
village of Bayou Sara. 

4. When treating of the epidemic of Woodville, we found that on a cer- 
tain plantation, a number of negroes who had not visited the town expe- 
rienced attacks of the fever after the death of one who had contracted it 
there ; but the author of this important observation likewise informs us, 
that the disease occurred on some plantations, where, as far as could be 
ascertained, it had not been introduced. There were, indeed, signs of an 
epidemic constitution for several miles around Woodville. 

5. By referring to the history of the yellow fever in New Orleans, for the year 
1841, the reader will find an account from Dr. Beugnot and Luzenburg, of 
its apparent introduction and spread by officers and seamen of the Talma, 
anchored off La Fayette, adjoining the city, where, as they state, the fever 
had not in any previous season commenced. 

If the history of the disease for the last fifty years in the Valley of the 
Mississippi furnishes any other facts going to show the contagiousness of 
yellow fever, I have not been able to find them. There are, however, 
two analogical arguments in support of this opinion, which must not be 
overlooked. 

1. The fever is not intermittent, but approaches to the continued type. 
Now typhus and typhoid, which are continued fevers, are known (or believed) 
to generate contagion ', and from analogy we might predicate the same of 
yellow fever. 

2. We have seen as a general fact that yellow fever affects persons but 
once, which, as all the world knows, is true of the eruptive fevers, and as 
they are contagious, we might conclude that yellow fever is the same. But 
on this method of analogical reasoning, yellow fever ought to be eruptive, 
as well as contagious. If it fail in one it may fail in the other also. The 
relation between eruption and contagion is in fact much closer than between 
immunity from second attacks and contagion, for typhus fever and syphilis 
are contagious and eruptive, yet second attacks of the former are not uncom- 
mon, and it is not proved that an attack of the latter bestows any immunity 
against future infection. 

There is, moreover, a difference between yellow fever and the true erup- 
tive fevers, as to exemption from second attacks ; for residence in a cold 
climate destroys it in yellow fever, but no change of climate has that 
effect in the eruptive fevers. Thus the contagiousness of yellow fever 
cannot be established by this any more than by the other. 

Let us now examine the facts which oppose the doctrine of contagion. 

If we look to small-pox, measles, and scarlatina, the best examples of 
contagious fevers, or even add to them typhoid and typhus fevers, we find 



INTERIOR VALLEY OF NORTH AMERICA. 289 

that they propagate themselves in all seasons, localities, and conditions, pro- 
vided the emanations from the body of the patient be not decomposed or 
wafted away ; but such is not the case with yellow fever. 

1. Thus, vessels arrive in New Orleans in the months of April, May, and 
June, from the Havana, when yellow fever is prevailing there, but the cases 
of fever which they bring, do not propagate the disease. Yet if contagion 
exist, why is it not as operative in those months as in August and Septem- 
ber ? It certainly differs from all other contagions, if it cannot exert itself 
as well be/ore as after the summer solstice. 

2. As soon in autumn as the cold becomes great enough to freeze the 
ground, yellow fever ceases, but cold does not, any more than heat, put a 
stop to small-pox, measles, and typhoid fever. And here again yellow fever 
fails to stand the test. 

3. The fevers just mentioned prevail both in town and country; but yel- 
low fever is almost limited to the former; — another failure. 

4. Small-pox, measles, and scarlatina, are propagated and become epi- 
demic in salubrious, as readily and certainly as insalubrious localities; 
which is not true of yellow fever. 

Thus we see that this disease does not conform to the laws of contagious 
fever. But stronger facts remain to be stated. 

Nothing connected with the whole subject is more definitively settled than 
that persons may die of yellow fever, both in town and country, without 
communicating the disease. Many accurately-observed and well-attested 
cases of this kind are scattered through our historical narratives; and a 
much greater number might have been given. Now, such events in such 
places are the true tests of the contagiousness of this disease, for no other 
alleged cause is present. In New Orleans and other commercial cities, in 
the latter part of summer and early autumn, there is another cause ; and 
how is it possible to analyze the phenomena, and say that one depends on 
that cause, and another on contagion ? It may be said, however, that the 
city atmosphere is not the direct cause of any of the phenomena, but the 
cause of the contagiousness of the fever. Thus, if two individuals in the 
same ship had received the semina of the fever in Havana, in the month 
of August, and one should be landed on a plantation below the city, and 
the other brought into it, and both should sicken, the city atmosphere 
would so act on the system of one as to cause it to secrete contagion, while 
the system of the other, surrounded by a pure air, would not secrete conta- 
gion — one would communicate the disease, the other not. As I know of 
no fact or analogy going to support this hypothesis, I am compelled to reject 
it ; but must not do so without remarking that it recognizes the necessary, 
though indirect, agency of a particular local condition of the atmosphere 
in the production of the fever. 

But another view may be taken of this matter, which is, that the predis- 
posing impress of impure air is a necessary condition to the action of the 

vol. n. 19 



290 THE PRINCIPAL DISEASES OF THE 

contagion, and consequently, that it produces no effect beyond the limits 
of such an atmosphere, and, therefore, seems not to exist, when it really 
does. According to the preceding view, contagion is not produced without 
the influence, on the body of the sick, of an impure atmosphere. According to 
this view, contagion is inert without the predisposing influence of an impure 
atmosphere on the bodies of the healthy. This recognizes the action of two 
causes, and if either be absent, the fever will not appear. It may be called 
the hypothesis of compromise, for it tolerates, or rather requires, all that 
both parties demand. As we have many examples of co-operative and suc- 
cessive influence of remote causes in the production of disease, this hypo- 
thesis wears a most plausible aspect, and has drawn to itself nearly all who 
once held to the doctrine of the sufficiency of contagion, and not a few of 
those who formerly believed in local causes exclusively. It accounts, in a 
general way, for the absence of the fever from filthy, but insulated towns, 
where but one of the causes exists ) for its frequent prevalence in commer- 
cial towns, which hold intercourse with those further south ; for its not ap- 
pearing in towns which are free from impurities, although cases of yellow 
fever may be introduced into them ; for its prevalence in autumn, when the 
air from the heat of summer is most impure, and for its cessation in win- 
ter, when the further development of exhalations is arrested by frost. It 
inculcates cleanliness to prevent the development of the predisposing cause, 
and non-intercourse with places where the fever is prevailing, to exclude 
the exciting cause ; prudently attending to both, lest the efforts to suppress 
either should be unsuccessful. 

Now the objections to this hypothesis are: — 

1. That it combines an admitted and an assumed cause : the local con- 
tamination is a fact — the contagion an assumption. 

2. That in many invasions of the fever cases have occurred under cir- 
cumstances which almost precluded the possibility of communication with 
the sick, and must therefore be referred to the admitted local cause. 

3. That the fever often appears almost simultaneously in various parts 
of a town, in the same manner as epidemic cholera, or as autumnal fever 
among the inhabitants of the country. 

4. That it has (as we shall hereafter see) commenced and prevailed in 
ships, and in some localities on land where the alleged exciting cause, con- 
tagion, could not possibly be. 

5. That having admitted one cause, which appears sometimes to have 
been sufficient, of itself, for the production of the disease, it is unphilo- 
sophical to admit another, the existence of which has not been proved. 

There is however another view which avoids the last objection, while it 
comprehends both local contamination and contagion. According to this 
hypothesis, contagion acts upon the impurities suspended in the atmosphere 
of places where and when the fever prevails, and excites in them an in- 
testine or fermentative action, which transforms them into its own nature. 



INTERIOR VALLEY OF NORTH AMERICA. 291 

This hypothesis of contagious fermentation proceeds on three assumptions : 
first, that contagion is a ferment ; second, that the gas or exhalation, which 
contaminates the atmosphere, is susceptible of fermentation j third, that 
the product is the same as the ferment which excited it. If either of the 
former of these assumptions fail, the hypothesis likewise fails, for there 
will be no fermentation. Bat not so with the latter; for it may be that 
the exhalations from the bodies of yellow fever patients never produced 
the disease in others by their direct action, are not in fact contagious, but 
only ferments, capable of transforming the impurities of the atmosphere 
into the true and only cause of the fever. 

The hypothesis of fermentation certainly avoids some of the objections 
which lie against that of contagious propagation by personal intercourse, as 
we may admit, that it can go on rapidly and in a short time transform the 
aerial impurities of a city into a poison, like itself, so that the fever may 
be produced simultaneously in various parts of the locality ; it also explains 
the production of a fever atmosphere in a particular portion of a city ; and 
finally accounts for the production of the disease in those who only ride 
through that part, which the doctrine of personal contagion does not. 

Nevertheless, it must not be forgotten that this hypothesis rests entirely on 
assumptions, as indeed the whole doctrine of gaseous or aerial fermentation 
does, and is, moreover, liable to some objections which I shall proceed to 
state. But previous to doing this, it will be proper to bring forward and 
incorporate with this, another branch of our subject. In the beginning of our 
inquiry, it was stated hypothetically, that if yellow fever were originally 
introduced into Havana, and thence upon this continent, it might have 
been done either by the importation of contagion, or of a portion of that 
atmosphere, or rather of its like, which produced the first case, and which 
acted as a ferment in the air of Havana. Now what I am about to say, 
will apply equally to both these alleged ferments, and embrace every 
possible case of importation. When a ship arrives in New Orleans 
from a yellow fever port, and brings patients with that disease, she has, we 
may admit, within herself, all the causes which prevail in the port from 
whence she sailed, the local summer atmosphere and the emanations which 
the sick send forth; and those who visit her may contract the disease 
precisely as if they had visited the town from whence she sailed ; but to 
make her arrival the cause of a subsequent epidemic, it is assumed that 
her foul atmosphere is the immediate eause of a transformation of the 
impurities suspended in the atmosphere of the city into the same kind of 
poison with itself, and thus she raises an epidemic. She does not merely 
add her own poisonous air to the impurities already existing in the locality, 
but impregnates them with a fatal leaven. 

Now can these alleged ferments act on every kind of gaseous impurity ? 
Certainly not. For when introduced into the atmosphere which produces 
autumnal fever, they excite no fermentation, effect no transformation, oc- 



292 THE PRINCIPAL DISEASES OE THE 

casion no yellow fever beyond their own limits. When yellow fever is 
epidemic in Mobile, for instance, steamboats run daily up the Alabama 
River, and lie at the wharves of Kahawba, Selma, and Montgomery, while 
their inhabitants are suffering under remittent and intermittent fever, yet no 
yellow fever appears. At New Orleans, while yellow fever is raging in the 
city, and especially near the river, the environs which lie contiguous to the 
cypress swamp in its rear, are ravaged by remittent and intermittent fevers. 
Lastly, up the Mississippi River, it is chiefly in the older towns, where the 
malarial impregnation has become feeble, and autumnal fevers are com- 
paratively rare, that yellow fever makes its appearance. If this were not 
the fact, the leaven of yellow fever would transform the malaria of autumn 
into the cause of that disease, and spread it over the whole country. We 
may take it then as a settled fact that the yellow fever leaven exerts its 
transforming power only on the impure air of certain localities, and that in 
absence of such impurities, there is and can be no spread of that disease. 
We have then in this state of the atmosphere over yellow fever localities a 
conditio sine qua non to the spread of that disease from the vessels which 
import the alleged ferments. But is this malaria of our commercial towns 
and cities inert and harmless of itself? By no means. For when and where 
yellow fever does not occur, these localities in summer and autumn are 
infested with a remittent fever, which bears so striking a resemblance to 
the remittent fever of the country, that every physician regards them as 
the offspring of the same cause in a state of modification. In the coun- 
try this agent is generated in swamps, and other humid places, where the 
recrements of plants and insects are subjected to decomposition, in the 
towns where yellow fever oftenest prevails, other vegetable recrements, 
animal exuvia, and exhalations and secretions from a dense population, are 
subjected to the same decomposition. As the decomposable materials are 
not identical, the products of fermentation cannot be identical. The rural 
malaria produces one modification of fever, the civic another. Now is it not 
remarkable, when these malaria approach so near to perfect identity, that 
the imported ferment should readily change the civic malaria into yellow 
fever gas, but produce no effect whatever on the rural malaria ? When the 
two, judging by their effects, so far from being distinct species are not even 
striking varieties, how is it that the foul air of Havana or the exhalations 
from the body of a yellow fever patient can start one into active and 
deleterious fermentation and be utterly inert when mingled with the other ? 
The hypothesis of ferments is bound to answer this question ; or else to 
establish itself by positive facts. 

This latter it has attempted to do in the following manner: — 

1. Ships from Yera Cruz or the Havana have almost always arrived in 
New Orleans just before an outbreak of the fever. 

2. During the war with England, when the intercourse with the more 
southern ports of the Gulf was suspended, or nearly so, the fever was absent. 



INTERIOR VALLEY OF NORTH AMERICA. 293 

3. Those places on the Gulf which have most intercourse with Havana, 
are oftenest invaded. 

4. The disease has almost confined itself in the interior to the towns 
which are visited by steamboats, and has occurred oftenest in those which 
are oftenest visited. 

5. They have frequently been invaded immediately after the arrival of a 
boat from New Orleans. 

6. The towns of the interior are not in general affected till the disease 
has prevailed for some time in New Orleans. 

7. It never appears in any of the towns of the interior when it is absent 
from Xew Orleans. 

8. It generally begins near the wharves. 

None of these facts can be questioned, but it is proper to estimate rigidly 
their value in reference to the theory which they seem to support, and this 
I shall proceed to do : — 

1. Ships are at all times arriving at New Orleans from Havana, Yera 
Cruz, and other southern ports of the G-ulf ; and, therefore, if the fever de- 
pended on a local or indigenous cause, developed in August and September, 
it could scarcely happen that the arrival of a ship would not be coincident 
with it. 

2. As to the absence of the disease before and during the war with 
England, it does not appear that it was absolute, for Dr. Huestis, in his 
account of the diseases of Louisiana, and Judge Chamberlain, now of Mobile, 
but then of New Orleans, assure us that the fever occurred in 1812, after 
the declaration of war. But its complete absence during that period would 
not be conclusive, for in 1815 and 1816, the two years which succeeded the 
three years of war, it was absent; and in many towns, as for example, 
Mobile, notwithstanding an unrestricted intercourse with both Havana and 
New Orleans, it has been absent for periods of two, three, and even ten 
years; Natchez, from 1829 to 1837; Baton Kouge, in which it did not 
occur from 1829 to 1839, and again was absent to 1843 ; to which it may 
be added, that many towns in constant communication with New Orleans, 
were not visited till 1839 ; thus effectually destroying the conclusion drawn 
from the relative absence of the fever during the war. 

3. If it occur oftenest in the towns which have most intercourse with 
Havana; oftener, for instance, in New Orleans than Mobile, and in the latter, 
than in Pensacola, the introduction and agency of a ferment is not proved; 
for in proportion as towns have more shipping, they have more nuisances, 
and a more crowded wharf population, and therefore send up more of those 
exhalations on which the ferment is said to act. 

4. If the disease is almost confined to river-towns, it may be because those 
exhalations which are to be fermented are there most copious. 

5. If the disease often shows itself soon after the arrival of a boat from 
New Orleans, it may be simply because a local influence is then matured. 



294 THE PRINCIPAL DISEASES OF THE 

The previous arrivals without the supervention of the fever, show, according to 
the theory of ferments, that the local atmosphere was not yet impure enough 
for the alleged fermentation ; when its impurity has become great enough 
for the fermentation, that process may or may not be necessary to an out- 
break of the fever. 

6. If the towns of the interior are not in general affected till some time 
after the disease has prevailed, that may arise from a slower development 
of the required local atmosphere, and not from a necessary lapse of time for 
the production of the ferment in the atmosphere of the city. The conditions, 
including heat necessary to a local contamination, are less active in the 
smaller towns north of New Orleans than in that city. 

7. That none of the interior towns have it when New Orleans is exempt. 
This only proves that the causes which exempt that city, to wit, the absence, 
not of an imported ferment, but a local impurity to be fermented, have been 
equally operative in the towns of the interior. 

8. If it generally appears in the neighborhood of wharves, it may be 
because the local contaminated atmosphere is there most concentrated. 

It appears then, that the facts admit of a different interpretation, and do 
not, therefore, establish the existence and importation of a ferment. But to 
take away the tendered proofs of a theory does not disprove, but merely 
leave it unsupported. In that condition I conceive the doctrine of ferments 
now to stand ) and in the absence of the support by facts, let us inquire into 
its probability and necessity. 

1. Although I have called it a theory, we see that it is only an hypothesis, 
an assertion to be proved — an assumption to explain certain facts, which 
admit of a different interpretation ; which, however, it must be granted, may 
not be the correct one. If, however, they can be differently explained, they 
can no longer be exclusively applied to the hypothesis to which they were 
referred, which before it can reclaim them must establish itself by other evi- 
dences. 

2. This hypothesis is not sustained by any known analogy, and, therefore, 
can derive no support from reasonings carried from the known to the un- 
known. 

3. It multiplies causes without having the necessity for them shown. If 
a peculiar impure state of the atmosphere is necessary to the action of the 
alleged ferment, it may be said that the disease arises from that atmosphere 
itself, independently of any transformation by fermentative action. This is 
only elevating a condition, which the other hypothesis admits, to the rank of 
a sine qua non in the production of the fever, the cause, and the only cause. 
It is substituting the impure exhalations themselves, before the alleged fer- 
mentation, for the products of that fermentation. Their existence is 
granted, indeed, demanded by the hypothesis of fermentations, for without 
them the ferments could not spread the disease ; but the very existence of 
the ferment is an hypothesis. If they necessarily exist, whenever the fever 



INTERIOR VALLEY OF NORTH AMERICA. 295 

occurs, they may be expected to produce some effect, for by the very terms 
of the case, they are impurities, and that effect may be — the fever. 

This brings us to the inquiry whether the theory of an indigenous atmo- 
spheric contamination can explain all the phenomena connected with the 
origin and epidemic prevalence of the disease, in doing which I shall take 
autumnal fever, a non-contagious endemic, for our model. 

1. Whatever may be the mode in which, or the medium by which yellow 
fever now spreads through a community, or appears successively in different 
towns, the first case of the disease cannot have been produced by morbid ex- 
halation from the body of one laboring under that disease, and must therefore 
be regarded as the product of a cause resulting from chemical action on mate- 
rials composing the earth, or resting on its surface. But if one case could 
be originated in that way, others may, indeed must, whenever the same con- 
ditions exist. The same conditions may not, however, exist but at the spot 
where the first case was generated, and the disease may everywhere else 
depend on derivation from those who labor under it. But we have shown 
as a matter of fact that it is not thus propagated. We have also shown that 
many facts and arguments stand opposed to the hypothesis of ferments. 

2. If we can show that the disease has arisen independently both of con- 
tagion and of ferments, under circumstances which deteriorate the atmo- 
sphere with the material on which the ferment is said to act, we have made 
out a case identical with that which originally produced the fever, and 
proved that it is still, as at its primitive appearance, a disease of local origin, 
the offspring of certain conditions, and a necessary occurrence whenever and 
wherever those conditions exist. 

What, then, are the proofs of this origin ? 

1. When treating of the origin of the fever at Pensacola, I have given 
the history of the generation of the fever on board of three national ships, 
the Natchez, Yincennes, and Hornet, altogether apart from any external 
influence ; and when giving its history at Donaldsonville, I stated an in- 
stance of its being generated in a small boat on a voyage from Baton Bouge 
to that town, the disease not existing in either. I might greatly extend this 
catalogue if I chose to introduce cases of a less rigid character, for the 
number of instances of alleged spontaneous origin on ships, in the Grulf of 
Mexico, is very great, but I do not wish to employ apocryphal data. 

2. Passing by New Orleans, where the local and commercial conditions 
are too much mixed for a satisfactory estimate of the influence of either, 
I may refer to Mobile, as having several times been invaded, in such parts 
of the city, and under such circumstances, as to convince the whole of its 
medical men, and all its observing population, that the fever did, indeed, 
arise independently of importation. I may also refer to Natchez, some of 
whose epidemics began under circumstances which seem utterly adverse to 
the hypothesis of importation; likewise, to the country around Washington, 
where we have the authority of Dr. Branch and Dr. Monette, the latter a 



296 THE PRINCIPAL DISEASES OP THE 

powerful advocate of importation, that the disease has occurred from local 
causes; to Apalachicola Bay, where, according to Dr. Hart, several cases 
occurred when no ships had arrived from a distance; to Fort Smith, where 
the disease appears to have prevailed in 1823 ; to Memphis, where it was 
epidemic in 1828, and as far as observation could guide those who witnessed 
it, arose from conditions existing on the spot ; finally, in our examination of 
the origin of the fever in all the times and places where it has prevailed in 
the Northern Basin of the Gulf, we found that in almost every case which 
admitted of a strict examination, the asserted importation of the disease 
could not be made out, but if it were not imported, it was of local origin. 

3. It does seem to me, then, that the fact of a local origin of some cases is 
as well established as medical facts generally are, and that we are at liberty 
to reason from it as a fixed datum. But does this prove that the disease is 
indigenous ? The answer must be in the negative. For it is possible that in 
all these cases a portion of the ferment may have been introduced long before, 
and lain dormant for want of that element in the atmosphere on which it 
is said to act, and it is also possible that when such an atmosphere was 
generated the ferment took effect. We cannot disprove this, and therefore 
admitting all the facts which have just been cited, they do not demonstrate 
that the fever arose from causes entirely local. But although that grade of 
proof is not attainable, we may certainly approximate to it; for in the first 
place the very existence of such a ferment is, as we have shown, an assump- 
tion ; in the second place, as it is represented to have been a product of the 
South, and as cold suddenly arrests the fever, it seems highly improbable 
that it could survive the action of several winters ; and in the third place, 
it is contrary to all analogy that it should neither undergo spontaneous de- 
composition through so long a period, nor evaporate, nor be absorbed by 
the bodies to which it adhered, through a series of years, and thus be lost. 
If these reasons do not annihilate the claims of the doctrine of a ferment, 
it must, I think, be admitted that it reduces them to the very lowest de- 
gree of probability. 

4. The occurrence of the fever from local conditions, independent of 
any foreign agency, being established in even a single instance, the contro- 
versy is, dejure, at an end, for if it can be thus generated in one case, it 
may in all, and to say that it is not, is to superadd a hypothetical to a 
known cause, in violation of the rules of philosophizing. He, indeed, who 
admits its production in this manner in one instance, and denies it in 
others, is bound to support his denial, — he brings upon himself the onus 
probandi. When a phenomenon has been once proved to arise from a 
certain cause, true logic requires us to refer it whenever and wherever it 
may afterwards appear to the same cause. If then yellow fever on board 
the Ship Natchez, or in the vicinity of Washington, or in the village of 
Memphis, arose from local causes only, it has arisen in every other town 



INTERIOR VALLEY OP NORTH AMERICA. 297 

through which we have travelled, from like causes, in other words is indi- 
genous. 

Having made this generalization, let us proceed to inquire whether in 
its history it conforms to the laws of the endemic fevers with which we pro- 
posed to compare it. 

1. It prevails in a certain season of the year, setting in about the time 
the surface of the earth has attained its maximum heat, and ceasing when 
the temperature is reduced below a certain point. 

2. While like autumnal fevers it extends indefinitely to the south, it 
has, like them, shown itself limited to the north, but the limits of the two 
diseases are not the same, the boundaries of the former being much higher 
than those of the latter. 

3. Within these limits it invades certain localities and is never seen in 
others, and the same is true of autumnal fever. From some it is scarcely 
absent any year, while others are invaded only now and then, and the same 
is true of them. 

4. In some seasons, as those of 1819, 1827, 1829, and 1843, but above all 
in that of 1839, it appeared as a widespread epidemic, while in others it 
has been limited to a few places, or even to New Orleans ; and autumnal 
fever varies in a similar manner. 

5. It is often seen to be influenced in its aspect by the cause of autumnal 
fever. The cause of typhoid fever has now and then produced modifications 
in its symptoms. In the year 1811, at Terre aux Boeufs and New Orleans, 
in the army, it was modified by scorbutus. During the prevalence of epi- 
demic cholera, in the latter, it assumed many of the characteristics of that 
epidemic. 

The whole of which is true of autumnal fever. 

6. In successive years, at the same place, it presents diversities which can- 
not be explained ; and in the same season, in different localities, variations 
of character have been noted ; which is also the case with autumnal fever. 

Thus conforming to nearly all the laws of our non-contagious, endemical, 
epidemic fever, it presents additional claims to be regarded as such. It 
meets in fact all the requirements of the theory of indigenous origin. 

Is yellow fever, then, it may be asked, merely the remittent autumnal 
fever with which we are all familiar ? The answer according to these views 
of its origin is, that it is one of the varieties, as a tertian fever is another. 
That it springs from a peculiar modification of the remote cause in the 
localities where it prevails; but that this modification is produced by local 
conditions, not by an imported ferment. That this variation in the cha- 
racter of the agent which produces it, is progressive. That the fever in 
June and July may wear the aspect and possess the intrinsic pathological 
nature of remittent autumnal fever, but in August, September, and October, 
display the more malignant character of yellow fever, returning in Novem- 



298 THE PRINCIPAL DISEASES OF THE 

ber to the milder form of an ordinary remittent, according to the tabular 
view presented at p. 197. 

Such is the malarial theory of this formidable disease ; that which is 
held by a majority of the physicians of the South; — a tbeory which incul- 
cates cleanliness and free ventilation in houses, yards, alleys, streets, boats, 
ships, and wharves, to obviate the development of civic malaria, which 
being prevented, the fever, according to this theory or according to the 
theory of an importation of ferments to act on that malaria, would equally 
fail to appear. 

But I cannot regard this theory as finally established, although obnoxious 
to fewer objections than the theory of ferments, for, — 

1. The whole pathological history of yellow fever seems to constitute it 
a specific fever, differing from an autumnal remittent too far to admit of 
its being a mere variety of that disease. 

2. It has occurred in localities where civic malaria can scarcely be admit- 
ted to exist, as in Washington and its vicinity, in the state of Mississippi ; 
in Opelousas, and in the Navy Yard on Pensacola Bay, where a white sand 
drift constitutes the surface of the ground. 

3. It has been produced by exposure to the air, which has escaped from 
goods sent from a city where the disease prevailed. [?Ed.] But I know of 
no facts which go to show that autumnal fever is ever produced in that 
manner. It is scarcely necessary here to repeat that there is no well-au- 
thenticated example of its spreading from this source. 

4. While the condition of a town to all visible appearance continues the 
same, the disease will appear and disappear, precisely as it does while the 
commercial intercourse with a place continues unchanged. 

Until these objections are removed, the cause of this disease should be 
kept subjudice. We are not compelled to choose among conflicting theories 
and declare that which is best supported to be established. It may be 
more probable than any other, and yet not be true. 



CHAPTER VII. 

SYMPTOMS. 

A volume would scarcely suflice for the delineation of the symptoms of 
yellow fever, as it has presented itself in different years, from Key West, 
Galveston, and New Orleans, up to Yicksburg and Memphis. But such a 
volume, if written, could be of little practical utility, inasmuch as the 
modifications of different years appear to be without limitation, and those 
which the future may bring forth, will no doubt vary much from the past. 
This diversity, moreover, is not confined to the epidemic of different seasons 



INTERIOR VALLEY OF NORTH AMERICA. 299 

and localities, but displayed in the same, according to the temperaments and 
idiosyncrasies of different individuals, and the nature of the exciting causes 
to which they have been exposed.^ Referring, therefore, to the respectable 
historians whose names are appended to this article, for the minutiae of de- 
tail, I propose to limit myself to such phenomena as seem best to demonstrate 
the specific character of the fever ; in doing which, as the physicians of the 
entire Valley are familiar with the symptoms of autumnal remittent and 
intermittent fever, with which yellow fever is supposed to have many close 
analogies and some identities, I shall frequently refer to them as terms of 
comparison. In those fevers we have a cold stage, a hot stage, and a secre- 
ting stage or intermission, which are separately described ; so in yellow fever 
there are three stages, which it will be convenient to consider separately 
under the heads of depression, reaction, and exhaustion. The symptoms of 
the two former are most diversified, and at the same time most ambiguous 
as it respects the true character of the disease. 

Stage of Depression. — The onset of yellow fever is in most cases sud- 
den compared with autumnal fever. It may be made either in the day or 
night, but appears to be oftener in the latter than in the former. In both 
it has, in some epidemics, been observed to occur oftener in the after, than 
the forenoon, and in the after, than in the fore part of the night ; indicating 
apparently the exciting influence of the opposite extremes of diurnal tem- 
perature in awakening the fever. 

The chill scarcely ever amounts to an ague, but is frequently protracted 
for several hours, alternating more or less with flashes of heat; in other 
cases it is not only protracted, but as severe as in algid intermittent fever. 
In some cases the patient complains of heat, when his skin is actually cold. 
The stomach is variously affected. The appetite may be lost or impaired 
for a day or two, but the instances are not few in which the disease has 
set in soon after a hearty meal. Although nausea and vomiting sometimes 
precede the chill for two or three days, they are not very common; and when 
retching does occur, the yellow bile so often thrown up in the beginning of 
autumnal fever is not often ejected in yellow fever, but in place of it a thin 
acid or greenish fluid. 

The tongue, sometimes, in the worst cases, is quite natural; in others is 
covered with white or yellowish fur along the middle, and while its edges and 
tip, in a few instances, are red in the beginning, they are oftener pale or sub- 
livid. A considerable degree of subgastric tenderness on pressure is not un- 
common. The bowels are generally costive, but in most cases easily moved ; 
and there is seldom much bile discharged under the operation of a cathartic. 
Thirst is often an early symptom ; but in some bad cases absent. The pulse 
is languid, frequent, and variable in fulness, though sometimes, in dan- 
gerous cases, almost natural both in force and frequency. Very opposite intel- 
lectual conditions may exist. In some cases the mind is feeble, depressed 
or alarmed; but in others, a high and playful mental excitement ushers 



300 THE PRINCIPAL DISEASES OF THE 

in the paroxysm j delirium sometimes occurs in this stage. Now and then 
the strength of the patient is greatly brought down ; but in the majority of 
cases, the reduction of muscular force is much less than in autumnal fever, 
and a considerable number of patients keep on their feet throughout the 
whole of this stage, although a fatal disease may have set in. 

The pain attendant on this stage, although less acute than in the next, 
and in some dangerous cases absent, is generally in the head, which then 
feels compressed; in the back, and in the limbs, and is often accompanied 
with yawning and a feeling of soreness in the muscles, and sometimes with 
spasms. 

In some cases there is great epigastric and thoracic oppression, with an 
anxious aspect of countenance. In other instances the physiognomy is 
stolid, or that of inebriation ; in all marked with indescribable peculiarities, 
which give important aid in diagnosis to those who have ever seen them. 

The characteristic redness of the eyes often begins in this stage. The 
expression of the organ is dull and the pupil sometimes dilated, in other 
cases intolerant of light. 

The intensity and duration of this stage vary exceedingly in different 
epidemics, and in different individuals during the fever. In many cases it 
terminates within a single hour — again it is protracted to twelve or even 
twenty-four, and in some instances, runs into the third stage, no reaction 
having taken place. Such cases present a marked resemblance to those 
malignant intermittents, in which the patient dies without the supervention 
of a hot stage ; as the cases of short chill and early reaction, resemble the 
first paroxysm of simple or inflammatory remittents. 

Stage of Keaction. — The transition from the stage of depression to 
that of excitement, of course, presents much diversity. In some it is sud- 
den and decisive, evincing a marked inflammatory type; in others a part 
of the functions are restored, while others remain suspended, a certain in- 
dication of danger. On the accession of excitement, the stomach becomes 
more irritable, with increase of epigastric tenderness and a sense of heat in 
that region. Vomiting frequently happens, but the discharge of bile is 
limited, and in many cases none whatever appears. The thirst becomes in- 
tense, the redness of the tongue increases, the organ becomes narrower and 
more pointed, and the mouth drier. The bitter taste so often present in 
autumnal fever is not in general felt. The force of the heart increases, and 
the pulse, retaining its frequency, becomes tense and sometimes hard. In 
many instances, however, a greater fulness is the only change which this 
stage brings about, and in a few in which it was nearly natural in the pre- 
ceding stage it continues so in this. The heat of the surface for the most 
part becomes intense, especially over the trunk of the body, which may 
happen while the feet continue cold. The pains now pass from dull to 
acute, and are often excruciating in the anterior part of the head, the orbits 
and balls of the eye, the back, and the limbs, especially the legs, the sur- 



INTERIOR VALLEY OF NORTH AMERICA. 301 

face of the body generally being sore under pressure. Delirium is common, 
but not constant, and occasionally the mind is composed and even cheerful. 
The insomnolence is perfect, and the patient, even when not delirious, some- 
times manifests a disposition to rise from the bed, walk about his chamber, 
and even dress himself, insisting that he is not ill. 

The red eye is now more developed than in the preceding stage — the con- 
junctiva, however, is dry, and there is no intolerance of light. The eye- 
balls often participate in the pain of the orbits. The expression, although 
more animated than in the stage which has just passed away, is not that of 
intelligence, but has been compared by nearly all our writers to the aspect 
of intoxication. As the disease advances, such parts of the conjunctiva as 
are not engorged begin to manifest a turbid yellow hue. In many instances 
the characteristic yellowness of the surface of the body, which gives name 
to this fever, begins to manifest itself in this stage, and is more perceptible 
in the face than in other parts. In other cases it is deferred till the next 
stage, or even till after death. The urine, secreted in sufficient quantities 
in the beginning of the disease, now diminishes, and becoming higher 
colored, and sometimes irritating, often ceases to flow before this period ter- 
minates. The alvine discharges are feculent, more or less of a drab or gray 
color, and sometimes tinged with yellow or dark-colored bile, but considera- 
ble bilious evacuations do not occur. 

The duration of the second stage like that of the first is various. In very 
mild or very malignant cases, it may end in twenty-four hours; but is much 
oftener continued to forty-eight or seventy-two — rarely extending beyond 
the latter. It is customary to speak of this as a single paroxysm ; but 
there is generally a slight abatement of the fever in the morning, which, 
however, increases in the course of the day, without the interposition of a 
chill, or the signs of a recurring stage of depression, like that which ushered 
in the fever. In some seasons and localities, however, a more decided re- 
mission occurs, indicating, it would seem, the modifying influence of the 
specific cause of autumnal fever. 

Stage of Exhaustion. — When the long paroxysm which has been 
described comes to an end, recovery seems at hand. The pains and bounding 
pulse and burning heat have ceased, and the contrast of the present ease 
with the preceding anguish, inspire both the patient and his friends with 
sanguine hopes. The danger may or may not have passed away; and in the 
beginning of this stage, the most experienced physicians cannot predict the 
issue. When the tendency is to recovery, the irritability of the stomach 
and the redness of the eyes diminish; the skin, kidneys, and liver resume 
their functions ; the intellectual faculties become natural, and the patient 
lies in a tranquil condition; all of which, however, by imprudent indulgence 
in diet, unwonted exertion, or exposure with the surface of the body not 
adequately protected may suddenly cease, or be replaced by symptoms which 
presage a mortal termination. To these, which constitute the distinguish- 



302 THE PRINCIPAL DISEASES OF THE 

ing characteristics of this fever, as compared not only with our ordinary 
autumnal fever, but every disease which prevails among us, we must now 
direct our attention. 

The redness and altered expression of the eye are apt to continue in this 
stage. Sometimes the patient is delirious ; in other cases his mental aber- 
ration inclines more to insanity, presenting an excited state of different feel- 
ings and passions, even the mirthful and lascivious. Again, he will be 
comatose, silent, and sullen. Although in some cases the exhaustion of 
muscular strength is extreme, in a greater number, there is unnatural 
strength, and a tendency to locomotion which the attendants can scarcely 
restrain. It is not uncommon for the patient to consider himself restored, 
or to see him attempting to engage in some kind of labor not an hour before 
his dissolution. 

The heart does not regain its exhausted power, and its irritability in most 
cases is so reduced that it contracts less frequently than in health, giving a 
slow, soft, and sluggish pulse. The respiration becomes infrequent, slow, 
and stertorous. The skin shows inactivity of capillary circulation, assuming 
more or less of a livid hue, with ecchymoses or petechiae ; being either dry 
and cool, or bathed in cold perspiration. The functions of the liver and 
kidneys are not restored, but on the contrary, all appearance of bile in the 
stools is lost, and the suppression of urine becomes complete. The gastric 
irritability is often extreme, but in ejecting what is swallowed, it displays the 
phenomena of mixed hiccough and sudden eructation rather than vomiting. 
The sensation of nausea does not appear to be present. The yellowness of 
the surface, which may have begun in the previous stage, now deepens, or 
absent then, now appears; though in many cases it does not show itself till 
after death, when in all it becomes much deeper than before. But one of 
the most characteristic phenomena of this stage, sometimes commencing in 
the previous one, is hemorrhage, which takes place from nearly all the 
mucous membranes, as those of the mouth, navel, bowels, urethra, vagina, 
and sometimes the eyes and ears; it occurs from the scarifications of the 
cupper, from leech-bites, and from blistered surfaces. At length the fatal 
black vomit, the nature of which I shall hereafter consider, at once deter- 
mines the true character of the disease and the probable fate of the patient. 

In some cases, the matter thrown up has been a transparent or slightly 
turbid, watery, or thin mucous fluid, with flakes or shining plates, resembling 
fragments of the wings of black butterflies, floating in it ; in others, a similar 
fluid has deposited an ash-colored sediment ; in others, it has been sanguino- 
lent; but in the majority, at the beginning, a dark-colored, flaky, or pulveru- 
lent matter, resembling coffee-grounds, swimming in a brownish-colored 
often viscid liquid, and constituting the true black vomit, precedes dissolu- 
tion. The length of time before death takes place after this symptom super- 
venes is various. In some cases it proves the immediate precursor of 
dissolution j in others, the patient lives for two or three days, during which 



INTERIOR VALLEY OF NORTH AMERICA. 303 

he will discharge great quantities, ejecting it frequently to the distance of 
several feet. 

Modifying Influences. — Four or five eccentric tendencies lead to 
many of the modifications, which, as we have just seen, the symptoms of 
yellow fever present. 

1. Many epidemics are characterized by the phenomena of ardent inflam- 
matory fever. They occur when there is a general atmospheric constitution 
of the phlogistic kind, which imparts to all febrile affections a more 
intensely inflammatory character. 

2. When a typhous epidemic constitution is prevalent, yellow fever pre- 
sents, in its symptoms, a tendency the opposite of the last. 

3. In a highly malarial state of the atmosphere, it shows, in its milder 
attacks, a leaning to the type of simple autumnal remittent fever — in the 
more violent, a simulation of congestive or malignant remittents, as has 
been already indicated. 

4. When epidemic cholera appeared in New Orleans, yellow fever was 
prevailing, and soon put on so many symptoms of that disease, that many 
cases were only recognized as such by the fatal hemorrhage and black vomit 
of the closing stage. 

An attention to these and facts of a similar kind, is necessary to a recon- 
cilement of the different histories of the disease ; and the great diversities 
of treatment which physicians of equal skill and veracity have reported as 
successful or prejudicial. 



CHAPTER VIII. 

* PATHOLOGICAL ANATOMY. 

We come now to inquire into the lesions of structure found after death 
in the fever which has been described. In doing this it will be impossible 
to connect them, severally, with the symptoms, as that can only be done 
in the histories of particular cases. Several of the post-mortem reports on 
which I must rely, were made from 20 to 25 years ago, when the true 
character of pathological appearances was not as well understood as at 
present ; others are partial as it respects the organs ; and others were made 
under the influence of preconceived opinions as to the character of the 
fever; all of which must diminish (I do not say to what extent) our con- 
fidence in their accuracy, notwithstanding the decided respectability of 
their authors.* In presenting the appearances, I shall review the organs 
affected, in succession, beginning with the digestive, and terminating with 
the blood, and its ominous derivative product — black vomit. The dis- 

* They are chiefly Drs. Lawrence, Barton, and Harrison. 



304 THE PRINCIPAL DISEASES OF THE 

sections of Dr. Cartwright were made at Natchez, in the epidemic of 1823, 
and 5 j of Dr. Merrill, same place, 1823 ; of Dr. Ticknor, in Key West, 1824 ; 
of Dr. Lawrence and Dr. Harrison in New Orleans, at various times ; of Dr. 
Ross, in Mobile, 1843 ; of Dr. Smith, in Galveston, 1839. 



SECTION I. 

SPECIAL LESIONS. 

The Stomach. — Dr. Cartwright, 1823.* The mucous membrane violently 
inflamed throughout its whole extent in a few cases ; in more, the lesion was 
limited to the greater curvature. In several cases in which the duodenum 
was violently inflamed, the stomach was entirely exempt from congestion, 
and its coats as firm and strong as usual. In a few cases the peritoneal 
covering over the lesser curvature showed signs of inflammation. There was 
generally an abundance of mucus. Black vomit was generally present 
either with or without vestiges of inflammation. In the epidemic of 1825, the 
same gentleman made a number of post-mortem inspections, and found no 
signs of inflammation in the majority. 

At Key West, 1824, Dr. Ticknor, f in two cases in which the stomach 
contained black vomit, found the mucous membrane engorged, thickened, 
and softened, so that the slightest force would detach it. 

Dr. Hulse, in dissections at various times, in the Naval Hospital, 
Pensacola, has observed the stomach to be contracted, its mucous coat 
corrugated, presenting sometimes dark, and other times rose-colored patches, 
while the large veins of the organ were filled with a black decomposed blood, 
and its cavity contained a fluid of nearly the same appearance. J 

In eight dissections at Galveston, 1839, Dr. Smith§ found black vomit 
and thickening and softening of the mucous membrane (always greatest near 
the pyloric extremity), which was sometimes injected, at others of a pearly 
white, anaemic. 

In a great number of dissections, at various times, in the Charity Hospital 
and city of New Orleans, Dr. Harrison || found the mucous membrane of this 
organ finely injected with blood, even when examined almost immediately 
after death. He also observed, in some, pit-like holes and furrows. In 
some cases the hyperaemia was confined to the cardiac and pyloric extre- 
mities; in others, was general, and frequently extended to the sub- 
mucous cellular tissue. In other cases the gastric membrane was entirely 
natural, but these were fewer in number. Softening was exceedingly rare. 
The organ generally contained black vomit, whether hyperaemia was present 
or not. In a few cases the membrane, after being Washed, presented a 
marbled appearance, the consequence, as he believes, of the use of an acid 

* Am. Med. Rec. vol. ix. f N. A. Med. and Surg. Jour. vol. iii. 

% Maryl. Med. and Surg. Jour. vol. ii. § Account of the Yellow Fever. || N. 0. Med. Jour, vol.ii. 



INTERIOR VALLEY OF NORTH AMERICA. 305 

solution of the sulphate of quinine ; as he found it practicable to produce 
that appearance by immersing the membrane in such a solution. 

Dr. Lawrance,* in New Orleans, in fourteen dissections, found the sto- 
mach extensively inflamed in six; topically or in spots, in five; slightly in 
two, and uninflamed in one only. In six the inflammation ascended several 
inches into the oesophagus. 

Dr. Slade,f in a single dissection at Vicksburg, found the mucous mem- 
brane universally injected. 

Dr. Ross,J in nine post-mortem inspections at the hospital, during the 
epidemic of Mobile, in 1843, found gas, black vomit, and a heavy coat of 
tenacious mucus in almost every one. In one or two the mucous mem- 
brane was extensively injected with blood, but in the majority red spots or 
points only were seen, the general area being white and anaemic. Some- 
times it was soft and tender, at others firm and apparently thicker than 
natural. 

Drs. Levert and Nott,§ of the same city, have in their occasional dissec- 
tions, found that membrane in a state of hypersemia and softening, but 
much oftener perfectly natural. They have seen it of a healthy, firm, and 
pearly appearance, when great quantities of black vomit rested on it. They 
have never seen it either ulcerated or gangrenous. 

Dr. Thomas,|| of New Orleans, in the epidemic of 1822, in connexion with 
Drs. Martin and Dupuy, made ten dissections in the Charity Hospital, and 
found the stomach inflamed in eight of them. In two, that organ was not 
inspected. In some of them the cardiac portion was most engorged. In 
the epidemics of 1819 and 1820 he had observed the same condition. 

Dr. Rushton, of New Orleans, in a considerable number of post-mortem 
examinations, has generally found the mucous membrane thickened, 
softened, and of a rose or deeper red color. Sometimes, however, to all ap- 
pearance perfectly sound, and yet containing black vomit. 

Dr. Mackie, of the same city, has in most cases found the gastric mem- 
brane injected, ecchymosed, thickened, softened, and sometimes ulcerated, 
but never gangrenous. When the discharge of black vomit has been copious, 
he has found the membrane blanched. 

Dr. Stone, during a long residence in the Charity Hospital, made a great 
number of dissections. He found the stomach oftener affected than any 
other organ, but in many cases it was entirely sound. The hyperemia was 
generally in patches, and the membrane was frequently softened, especially 
when the examination id as postponed. 

Dr. Kennedy, in the private hospital of which he is a proprietor, has 
ascertained, that in three-fourths of his cases the gastric membrane is 
thickened, engorged, and sometimes ecchymosed. 

The Duodenum. — As the morbid appearances which are found in the 

* Phil. Jour. Med. and Phys. Sci. toI. x. t SIS. Mem. % Ibid. § Ibid. 

II Essai sur la Fievre Jaime. 

VOL. II. 20 



306 THE PRINCIPAL DISEASES OF THE 

duodenum, are substantially the same kind with those of the stomach, mi- 
nuteness of detail will not here be necessary, and depending on the autho- 
rities already cited, I shall in the remainder of this chapter only refer to 
them by name. 

Dr. Cart wright and his venerable friend Dr. Tooley,* found the ravages 
of violent inflammation much oftener in the duodenum than stomach; and 
in several subjects they were present in the former, while absent in the lat- 
ter. The bowel was often lined with a thick layer of mucus and frequently 
contained black vomit, sometimes when the stomach did not. In two 
cases Dr. Ticknor found the same condition. Dr. Smith has sometimes seen 
this bowel of a deep brick-red, with prominent papillae, giving it a granu- 
lated appearance ) at other times natural in appearance, but distended with 
gas, and abounding in mucus and black vomit. 

Dr. Lawrance, in the whole of his fourteen examinations, found the duo- 
denum inflamed except in one. 

Dr. Slade found it highly inflamed in his single dissection. Dr. Hulse 
has seen the veins of the peritoneal coat of this bowel distended with dark 
grumous blood, and the mucous membrane affected with rose-colored spots, 
at the same time containing black vomit. Dr. Harrison has observed hy- 
peremia of the bowel, and in other cases seen it quite natural. Dr. Smith 
has found the signs of duodenal disease uniformly less than of gastric. Dr. 
Stone has found this bowel as often affected as the stomach • Dr.* Kennedy 
oftener. Dr. Ross has found it less affected than the stomach. 

The other Intestines. — These often contain black vomit. They are 
sometimes more or less engorged, but on the whole less affected than the 
duodenum. Dr. Lawrance found the other small bowels inflamed in two- 
thirds of his cases, and the colon in about one-fifth. In one dissection Dr. 
Slade found the jejunum and lower part of the ileum decidedly inflamed. 
Dr. Kennedy has seen the glands of Peyer swollen and ulcerated, a condition 
which probably existed before the attack of fever, as its course is in general 
too short to admit of ulceration. Dr. Harrison, however, has noted the same 
thing as an occasional appearance. Extensive intussusceptions are occasion- 
ally encountered unattended, generally, however, with inflammation. A 
patient of Dr. Barton died of violent inflammation of the rectum, supposed, 
however, to have been occasioned by the irritation caused by the un- 
authorized and repeated use of the glyster pipe. Dr. Ross has seen their 
mucous membrane soft when it was not engorged. In most cases they con- 
tain a dark fluid, which is often blood but little changed. Dr. Smith has 
noticed, in several cases, a tumefaction of the glands of Peyer ; he has seen 
patches of hyperaemia in various places. Black vomit was common. In one 
case the colon was remarkably white and contracted. 

The Liver, G-all-bladder, and Bile. — Dr. Cartwright found the 
liver in most of his dissections somewhat enlarged. It was generally of a 

*Hesl. Yellow Fever in New Orleans, 1823: 



INTERIOR VALLEY OF NORTH AMERICA. 307 

greenish hue, and in one or two cases black. In every instance the portal 
vessels were engorged with black blood. The serous membrane on its pos- 
terior surface, and the cellular substance investing the great vessels of that 
neighborhood, were always more or less inflamed. The gall-bladder always 
contained a black, ropy bile, and in one case its parietes were black but not 
mortified. The efferent ducts were generally in a natural state. In all 
cases Dr. Smith observed a deficiency of bile, but in none any structural 
derangement of the liver. Dr. Hulse has generally found the liver pale, 
though sometimes presenting livid patches; when cut into, black dirty- 
looking fluid blood gushed out in large quantities. Dr. Harrison has not 
seen any lesion of this organ which he could attribute to the fever. In 
some subjects it contained less blood than usual, and was of course pale and 
dry, — in other subjects it was engorged and bled freely when cut. In cases 
which had been treated by copious bloodletting it was generally of a pale 
yellow. In most cases the gall-bladder has contained its usual quantity of 
healthy bile ; but in a few, that fluid was replaced with a little glairy 
mucus. He has seen the mucous lining of the cyst injected in spots 
with blood, but in most instances it was healthy. Drs. Levert, Nott, and 
M'Nelly have not observed any particular morbid appearance. Sometimes it 
is a little yellower and larger than usual. The gall-bladder is often dis- 
tended with dark viscid bile which by dilution assumed a yellow hue. Dr. 
Ross has generally found the liver much altered, of a dark blue, a brown 
and a lemon color; almost always softened and affording a large quantity 
of blood. In one case soft and dry. The gall-bladder has generally con- 
tained a quantity of thick, blackish, or dark green bile. In one case he 
found its parietes much thickened. Dr. Rushton has seen the liver yellow 
in all cases in which the skin assumed that hue, but is not aware of any 
structural lesion ; and like all the observers named has never seen it in a 
state of suppuration. Dr. Mackie has commonly found the organ of an 
olive hue, its texture firm, but its vessels engorged with blood, except when 
copious hemorrhage had preceded death. Dr. Stone has often seen it pale 
or nearly natural, in a few cases engorged. Dr. Kennedy has in most in- 
stances found it normal, except that its color has been that of the skin, and 
the gall-bladder oftener empty than full. 

Out of fourteen cases Dr. Lawrance found the liver pale, or ash-colored 
in seven, in several of which it had the appearance of being parboiled. In 
two it was dark or brown. In three it was natural in color. In the other 
two the color was not noted. In one case he found it unnaturally small, in 
another too large. A single case only is noted of sanguineous engorgement. 
One as being hard and one soft. In almost every case the pori biliarii and 
hepatic ducts, were destitute of bile or contained a small quantity, generally 
of a very pale or dark and dirty hue. 

The gall-bladder in one case only was filled with healthy bile — in one 



308 THE PRINCIPAL DISEASES OP THE 

with transparent mucus. In general it contained a small but variable quan- 
tity of dark greenish or yellowish fluid. 

Dr. Slade's patient had a liver of a light drab color, and destitute of 
blood except in the larger vessels. The ducts were nearly destitute of bile 
and the gall-bladder contained but a small quantity, which was dark and 
tenacious. 

The Spleen. — Dr. Cartwright generally found this organ somewhat en- 
larged, when the stomach was not inflamed. In a case which had been pre- 
ceded by intermittent fever, it was so tender as to fall to pieces on being 
handled. The cellular membrane connecting the organ with the stomach 
and pancreas was generally in a state of congestion. In one case of two, 
Dr. Ticknor found the spleen enlarged, but not otherwise altered. Dr. 
Harrison has generally observed it sound — now and then engorged with 
blood. In one case out of several, Dr. Thomas witnessed enlargement. Dr. 
Smith in almost every dissection found it natural. Dr. Rushton has seldom 
seen it engorged — generally normal. Dr. Stone and Dr. Kennedy have in 
most cases found it natural ; on the contrary, Dr. Ross has frequently seen 
it engorged, enlarged, softened, and almost diffluent, though sometimes 
normal. Dr. Lawrance found the spleen in two of his cases large, blue, and 
tender. 

The conclusion of Louis, from dissections made at Gibraltar in 1828, 
that the true anatomical character of yellow fever is to be found in the 
color of the liver, having been adopted by some of our physicians, I have 
thought it worth while to bring it to the test of our own post-mortem exa- 
minations. According to that distinguished pathologist, the organ is 
'•'Sometimes of the color of fresh butter, sometimes of straw color, some- 
times of the color of coffee and milk, sometimes of a yellowish-green color, 
or a mustard color, or finally, sometimes an orange or pistachio color."* This 
discoloration he regards as characteristic of yellow fever. His generaliza- 
tion was founded on twenty-three dissections. For the purpose of comparison, 
I have carefully analyzed thirty-eight cases, the details of which have been 
reported by Lawrance, Cartwright, Smith, Ross, Barrington, Ticknor, Barton, 
and Slade, chiefly the first four, and here are the results : natural, 6 ; green 
and greenish, 5 ; natural, dappled with drab, 4; drab, 3; light, 3; pale, 3; pale 
ash, 2 ; black and dark, 2, reddish-brown and brownish, 2 j dark blue, 2 ; 
lemon, 2; mahogany, 1; sole-leather, 1; fawn, 1; chocolate, 1. 

With these facts before us, it is impossible to admit that the true and 
universal anatomical character of yellow fever is to be found in a discolora- 
tion of the liver, much less in any particular hue. Louis has added to this 
discoloration a dry and anaemic state of the organ, which, however, he did 
not find as uniformly as the discoloration. This condition existed in a 
number of the cases we are now examining, but in many others, the organ 

* Anatomical. Pathological, and Therapeutical Researches on the Yellow Fever of Gibraltar. Shat- 
tuck : s Trans, p. 117. 



INTERIOR VALLEY OF NORTH AMERICA. 309 

was engorged with blood, and, therefore, we cannot admit dryness as a true 
and invariable characteristic of the fever. It is not difficult to understand 
why the liver should present a great variety of hues. The delicate coloring 
matter of the bile is no doubt susceptible of many changes of tint under 
the influence of agents or mordants developed in the blood or the secretions 
during the fever ; and as to the anaemic or hyperaemic condition of the 
organ, it may often perhaps depend on the extent of the hemorrhages into 
the stomach and bowels before death [or excessive depletion during life. 
—Ed.] 

These remarkable contrarieties have no doubt resulted, in part at least, 
from previous attacks of intermittent fever in some of the patients. 

The Pancreas, mentioned by a few observers only, has been noted as 
sound, except in three of Dr. Lawrance's dissections, in which it was large 
and vascular, and bloody water was infiltrated into its substance in one. 

The Mesenteric Ganglia. — Dr. Harrison, and a few other observers, 
have noticed enlargement of these ganglia, especially in cases that termi- 
nated after the seventh or eighth day. Dr. Lawrance saw a case in which 
the mesentery presented extravasated, bloody-looking fluid in its cellular 
tissue. 

The Kidneys, Bladder, and Urine. — According to Dr. Cartwright, 
the adipose substance in which these organs are imbedded, was nearly always 
of a scarlet hue, which was more developed in proportion as the suppression 
of urine had been more complete. In a few cases the cortical portion ex- 
hibited appearances almost gangrenous. On cutting and squeezing the 
organ, grumous blood issued from the tubuli uriniferi. The bladder was 
sometimes thickened in its parietes, and contained a small quantity of red- 
dish, fetid urine. On the other hand, Dr. Smith found the kidneys sound 
in every case. The bladder was generally empty and contracted, but in one 
case he found it nearly full of limpid urine. In another, the quantity was 
smaller, with flakes of white mucus, and the entire internal coat was gorged 
with blood, giving it the appearance of the lining membrane of the eyelids 
in conjunctivitis. In a single subject, immediately below, and rather behind 
the kidneys, near the spine, on each side, there was a clot of blood in the 
cellular tissue, three inches long and half as much in width. Dr. Harrison 
has generally observed the kidneys to contain a great deal of blood, but on 
cutting into them, he could seldom find any appreciable lesion of structure. 
In some cases, the lining membrane of the pelvis was spotted with blood, 
an appearance which the bladder occasionally offered. Dr. Ross, in almost 
all his dissections, found these organs in a diseased state ; frequently en- 
larged, engorged with blood of a dark red or brown color, sometimes, how- 
ever, unnaturally pale, often dry, generally softened, but sometimes unu- 
sually firm. The bladder generally contained a notable quantity of urine, 
which was in most instances of a healthy quality. 

Dr. M'Nelly, of Mobile, has often seen the bladder distended after death, 



310 THE PRINCIPAL DISEASES OF THE 

especially in those who live for sometime after the setting in of the third 
stage. 

Dr. Lawrance, in three out of fourteen dissections, found the kidneys 
highly vascular, red, and tender. In another, there were coagulated extra- 
vasations into their substance and pelvis. In another, extravasations of 
blood around them; in another, they were of a blue color. In one case he 
found no urine ; in another, a moderate quantity, of a yellowish hue j in 
another, the bladder distended with the same, and in another, it was dis- 
tended with a bloody fluid. 

The Peritoneum appears to have been healthy, except the duplicatures 
forming the omentum, which a few of the observers note as being in a state 
of hyperemia ; and Dr. Lawrance found in one case a considerable quantity 
of bloody serum in the cavity. 

Let us now ascend to the chest, beginning with 

The Lungs. — Dr. Cartwright informs us that in some cases a considerable 
portion of the lungs resembled the liver both in weight and appearance. 
Under pressure after cutting into them a frothy liquid was discharged. In 
one or two of Dr. Ross's cases, these organs were engorged with blood — in 
all the rest, they seem to have been in a normal condition. Dr. Hulse found 
them abundant in dark-colored blood, with spots of the same hue on their 
surface. Dr. Smith found them, generally, normal. Dr. Harrison the 
same, though he has met with cases in which they were engorged, and did 
not collapse as usual. In a single instance he found a coagulum of extra- 
vasated blood. In a number of cases the mucous membrane of the bronchi 
and trachea was finely injected. Dr. Lawrance in his fourteen cases noted 
the lungs as sound and natural in one-half, engorged more or less with blood 
in five ; of two nothing is said. In one case there were several ounces of 
yellowish fluid in the chest, although the lungs were healthy — in another, 
in which they were engorged, there was a considerable quantity of bloody 
fluid. 

The Pleura appears not to have been found inflamed. In a few cases 
it contained more serum than usual. 

The Heart. — In a great majority of Dr. Cartwright's cases, the cavities 
of the heart contained polypi or fibrinous concretions, which sometimes 
were so large or numerous as actually to distend the organ. In their sub- 
stance were cells filled with yellow serum. At other times the organ con- 
tained a considerable quantity of blood resembling molasses in color and 
consistency, an abundance of which was likewise contained in the venae 
cavse near the heart. In several subjects spots an inch in diameter, the 
product apparently of inflammation, were found on the outer surface of the 
organ. Dr. Harrison informs us that coagula (polypi) are generally found 
in the heart, and contain an unusual quantity of coloring matter. In seve- 
ral subjects the endocardium presented spots analogous to the petechias of 
the skin. Dr. Smith found the heart sound. Sometimes there was an 



INTERIOR VALLEY OF NORTH AMERICA. 311 

unusual quantity of yellowish serum in the pericardium. Dr. Ross gene- 
rally found the heart normal. In one or two subjects its parietes were 
softened, but as they were also dilated, the whole probably existed before 
the fever set in. In one case the pericardium adhered, but we are not 
told whether by new or old lymph. Drs. Levert and Nott have occasionally 
seen the heart softened. In fourteen dissections Dr. Lawrance found the 
heart tender and easily torn in one, and its cavities very turgid with blood 
in two ; in the others it was either natural or not reported. In a case in 
which there was effusion of yellow fluid into the cavity of the pleura, there 
was also the same into the pericardium. 

We come now to the nervous system, beginning with 

The Brain. — According to Dr. Cartwright, the pia mater and arachnoid 
were in all his subjects except one more or less inflamed throughout their 
whole extent. The same was true of the velum interpositum and pia 
mater, the latter exhibiting a scarlet tint. In most cases the lateral ven- 
tricles contained a quantity of yellow serum, and in one eight ounces of 
such serum were found effused upon the surface of the brain, the mem- 
branes at the same time showing marks of inflammation. The fibrous 
membranes of the brain and cranium, within and without, showed no signs 
of inflammation, only bloody dots or points. The pia mater, especially 
about the tuber annulare, was almost always inflamed in those who had been 
delirious. Dr. Harrison has sometimes seen the pia mater finely injected. 
Occasionally the dura mater presented the sanguineous dots just mentioned. 
A moderate quantity of serum on the surface or in the ventricles of the 
organ was not uncommon. In some subjects the substance of the organ 
was engorged with blood, but generally it presented no appreciable lesion. 
Dr. Stone has often examined the brain. In a number of cases he met 
with venous engorgement ; in a few, traces of coagulable lymph ; but on 
the whole but little alteration. In one dissection Dr. Thomas found the 
membranes of the brain, particularly the plexus choroides, engorged with 
blood, and a considerable extravasation of black blood in the ventricles. 
Dr. Ross did not examine the brain. Of his fourteen cases Dr. Lawrance 
has reported the condition of the brain in only six. In one of these it was 
much engorged, in two others the vessels of its exterior were greatly dis- 
tended with venous blood ; in one the plexus choroides was highly injected, 
and of a deep red; in two there was serous effusion into the ventricles. In 
one of the cases in which the external vessels were engorged, the corpus cal- 
losum was of a bluish color and in common with the whole brain had a 
peculiar putrid odor, though the examination was made only twelve hours 
after death. 

The Spinal Cord. — In four examinations Dr. Cartwright found the 
fibrous investment free from disease. In the whole of the same subjects 
the arachnoid and pia mater were inflamed, chiefly in the lumbar and 
sacral portions, but less intensely than within the cavity of the skull. 



312 THE PRINCIPAL DISEASES OF THE 

There was frequently a scarlet hue about the origins of the nerves, both of 
the spinal cord and the medulla oblongata. In one subject there was a 
large quantity of yellow serum in the cervical portion of the theca. Dr. 
Harrison has not detected any affection of the membranes of the spinal 
cord. Dr. Thomas, on the contrary, who did not generally examine the 
brain, but directed his researches carefully upon the cord, found its serous 
membranes, in almost every case, displaying marks of inflammation, leading 
him to think that this condition always exists in yellow fever. Dr. Ross 
did not examine this organ, which appears to have been generally neglected 
in yellow fever dissections. 

The Ganglions and Plexuses of the G-reat Sympathetic. — Dr. 
Cartwright is the author to whom we are indebted for all that can be said 
on this subject. In his account of the Natchez epidemic of 1823, after ex- 
pressing dissatisfaction with the result of his examination of the abdominal 
viscera, as not illustrating the pathology of the fever, he observes : " I at 
length determined, if possible, to find out the nature and seat of the malady, 
not only by examining the abdominal viscera, but the brain, the spinal 
marrow, and every part of the system. It was then that I discovered the 
diseased state of the ganglions, the ganglionar!/ nerves, and the inflamma- 
tion of their investing membranes. The semilunar ganglions, and coeliac 
plexus, were, in particular, highly diseased. The membranes immediately 
investing these ganglions and their plexuses, were of a deep scarlet, and in 
some places, of a black color. This inflammation was not confined to the 
tissues immediately investing the nerves, but extended to the neighboring 
tissues, especially of the semilunar ganglion. The whole of the membranes 
enclosing the nerves, denominated the solar plexus, lying upon the cceliac 
and superior mesenteric arteries, were black with inflammation. The cel- 
lular substance investing the hepatic plexus, as it extends on the hepatic 
artery and vena portarum, the splenic, the mesenteric, and renal plexuses, 
together with the cardiac and pulmonary plexuses, were found to be of a 
scarlet color. In a word, the delicate tissues investing the whole of the 
ganglionic system of nerves, were more or less inflamed. Of twenty subjects, 
in the yellow fever of Natchez, in 1823, the ganglionic system of nerves were 
minutely and closely examined in seventeen; in the other three they were 
not. In these seventeen subjects, there was not a case in which the invest- 
ing membranes of the ganglions and their plexuses were not highly inflamed. 
In all these examinations after death, notes were taken at the time they 
were made, and many of them were witnessed by Drs. Gustine, Denny, and 
Tooley. A very good view of the tissues, which were always found inflamed 
in yellow fever, and which were more highly so than any other tissues in 
the whole system, could be had by taking out the thoracic and abdominal 
viscera entire, together with the aorta, and turning their posterior part 
uppermost. The membranes behind the great vessels of the lungs, envelop- 
ing the posterior pulmonary plexus ; and the membranes on the anterior 



INTERIOR VALLEY OF NORTH AMERICA. 313 

part of the aorta, down to its bifurcation, but particularly those about the 
root of the coeliac artery, investing the semilunar ganglions and their 
plexuses, were always of a deep scarlet or black color, which, like the 
color produced by indelible ink, defied ablution. The appendix of the dia- 
phragm was also, in the most of cases, very much diseased. 

"On looking into the subject after the viscera were removed, the whole 
fleshy substance of the psoas muscles was generally found to have undergone a 
great change of state, from its healthy condition. In some cases, these mus- 
cles were of a black color, and easily torn. The fleshy part of the iliacus inter- 
nus, where it arises from the transverse process of the last lumbar vertebrae, 
and from the hollow of the ilium, was diseased in common with the psoas 
muscles. 

"Besides these dissections in the yellow fever of Natchez in 1823, 1 made 
an examination of a patient who had died of the yellow fever of New Or- 
leans in 1824, and also a sporadic case of the disease in Natchez, since 1823. 
Dr. Hunt, of Natchez, assisted me in the examination of the latter. In both 
these cases, the ganglionic system of nerves was found to be diseased in the 
same manner as in the seventeen cases in which these nerves were examined 
in 1823." — [Extracted by Editor.*] 

In all the published accounts which I have been able to collect, I find 
but one reference to the condition of these portions of the nervous system, 
which is by Dr. Harrison, who has generally found in them " no appreciable 
lesion." Dr. Stone informed me that he had several times examined the 
solar plexus and semilunar ganglions, without realizing Dr. Cartwright's 
discoveries, having not found in them any particular departure from a 
healthy condition. 

The Muscles of Animal Life. — Several of the Mobile physicians 
have observed that the muscles appeared to be a little softened, and do not 
become as rigid as after death from common causes. Dr. Lawrance men- 
tions two cases in which the muscles of the limbs or trunk, were soft, ten- 
der, and full of blood. Dr. Smith, however, speaks of the limbs as being 
rigid ; and others are silent. 

The Skin. — Generally of a sallow hue, especially over the face, neck, and 
breast, before death. The skin becomes, afterwards, in most subjects, uni- 
versally yellow. In a few, this complexion is modified by a leaden, or a 
dark and dirty hue. Petechial spots are often scattered over this ground. 
Dr. Lawrance has observed that the scalp abounds in blood, which is some- 
times extravasated into, or beneath, as it is found in patches occasionally 
elsewhere. 

* American Med. llecorder, vol. ix. p. 37. 



314 THE PRINCIPAL DISEASES OF THE 

SECTION II. 

GENERALIZATIONS. 

I. Most of the morbid appearances set forth in the preceding section, 
are hyperemias or congestions of blood, sometimes arterial sometimes venous. 
In many cases, no doubt, there were actual inflammations ; but we are 
scarcely at liberty to regard the appearances observed as entirely due to 
that lesion, for mere hyperemia cannot be regarded as proof of inflammation. 

1. We are not told by most of the observers that the blood of the reddened 
tissues could neither be pressed out nor washed away ; and nothing indi- 
cates that any allowance was made for post-mortem accumulations. These 
negative facts would not, however, be worthy of attention but for the fol- 
lowing, which although likewise negative, are entitled to consideration. 

2. The softening of the tissues, although frequently mentioned, does not 
seem to have been commensurate with the hyperemias. 3. The effusions, 
serous and lymphatic, attendant on that mode of morbid action, have gene- 
rally been wanting. Indeed examples of lymphatic effusion are scarcely 
to be met with. 4. We have not a single instance of suppuration. 5. 
Scarcely an instance of ulceration is mentioned. 6: Not a single case of 
gangrene has been offered to our notice. 7. Hemorrhage, which is so sel- 
dom associated with inflammation, has been frequent. These hemorrhages 
have often been in stellated spots into the cellular tissue of the organs or 
skin. When such spots have been found in the midst of an extended 
hyperemia, they have been regarded as signs or effects of inflammation, 
but as they have often occurred in the same subjects where there was no 
inflammatory congestion, as in the skin, for example, we cannot admit them 
as unequivocal signs of inflammation when found in the internal tissues. 
8. The greater number of observers have reported the blood drawn in 
yellow fever as destitute of a si'zy crust. 9. It is unquestionable, as we 
shall hereafter see, that yellow fever has often been aggravated by copious 
bleeding, and cured by means not adapted to the removal of inflammation. 
10. The number or extent of these hyperemias in the same subject is cer- 
tainly not favorable to the theory of inflammation. 

In view of these facts, we must, I think, regard many of the reported 
vestiges of inflammation as simple congestions. • 

II. In referring to the relative frequency of these in the different organs, 
we must admit the greatest number in the stomach and duodenum ; though 
they are not uniformly met with in either. When present in one, they 
have been absent from the other, et vice versa ; but in many cases they 
have occurred in both. Of the other intestines, the smaller have been oftener 
affected than the larger. Dr. Lawrance only has mentioned inflammation 
of the esophagus. 



INTERIOR VALLEY OF NORTH AMERICA. 315 

III. The liver appears to have suffered but little, at least from any kind 
of vascular engorgement ; though in most cases, its secretory function has 
been greatly impaired ; in some quite suspended. Its efferent tubes have 
been unobstructed, and still they have not poured out bile, nor did they 
contain that fluid in the usual quantity. It appears conclusively, then, 
that the yellowness of the skin, and sometimes of other tissues and of 
secreted fluids, is not owing to the resorption of bile, elaborated in the 
liver, but to a suspended action of that organ, and the development in the 
blood, of the coloring matter, and, perhaps, other proximate elements of 
that fluid ; a process which continues after death, to the production in many 
cases of a deep, universal post-mortem jaundice. Thus the biliary derange- 
ment is peculiar. The production of the elements of the bile continues, 
is perhaps increased, but the liver has lost its ability to combine and ex- 
crete them ; an impairment of function which, as far as pathological ana- 
tomy teaches, does not depend on inflammation of that organ. 

IV. The spleen is but little affected in yellow fever, even less than in 
typhus and typhoid fevers, incomparably less than in autumnal intermit- 
tents and remittents. Dr. Ross found it oftener disordered than any other 
observer ; but intermittents are common in and around Mobile, where his 
observations were made. 

Y. The morbid appearances in other portions of the digestive organs 
have been still rarer, and, as it were, more accidental than those of the 
organ just mentioned. Of peritonitis, either abdominal or visceral, the 
vestiges have been exceedingly slight. 

VI. The kidneys and their cellular and adipose beds have felt the force 
of the disease, but not in a majority of cases, nor always in the form of in- 
flammation — sometimes in that of hemorrhage. Like the liver, they have 
frequently failed in their specific function, but the suspended evacuation of 
urine has much oftener arisen from retention in the bladder than is gene- 
rally supposed. In many cases, that organ has lost its power of contraction 
before the kidneys have lost the power of secretion, and hence the bladder 
has been found distended, not however, with healthy urine. 

VII. The morbid appearances within the chest have not been so constant, 
extensive, or well-defined as to constitute an important anatomical character, 
and cannot, indeed, be regarded as denoting anything more than incidental 
affections, seldom of a true inflammatory kind. 

VIII. The brain and its membranes have been oftener the seat of ana- 
tomical lesion than the heart and lungs, or even the liver ; but effusions of 
lymph have been seldom seen, which, considering the great extent of serous 
membrane within the cranium, seems to indicate that the morbid action has 
not always been inflammatory. On the other hand, extravasations of blood 
and serum have occurred, and on the whole, we may conclude that the 
affection of this organ has frequently been that of non-inflammatory san- 
guineous engorgement. In many cases it seems to have been but little 



316 THE PRINCIPAL DISEASES OF THE 

affected; we may, at least, without hesitation, believe that yellow fever may 
run its course to a fatal termination without leaving any appreciable lesion 
of that organ. 

The examinations into the condition of the spinal cord have been com- 
paratively few. Its lesions appear to resemble those of the brain. 

IX. The reports by Dr. Cartwright on the morbid condition of the gan- 
glia and plexus of the great sympathetic, stand unsupported by those of 
other observers. It is not likely that such important lesions should have 
been overlooked for twenty years. We must, I think, believe that the ap- 
pearances observed by Dr. Cartwright belonged more especially to the epi- 
demics in which he practised, and are not an invariable anatomical character. 

X. It results from all that has been said, that as yet no special, invariable, 
and universal lesion of structure, characteristic of our yellow fever, has 
been discovered ; but that vascular derangements of gastro-enteric mucous 
membrane are most frequent. 

Let us now turn our attention from the distribution to the condition of 
the blood. 



SECTION III. 

LESIONS OF THE BLOOD. 

To ascertain the state of the blood in reference to its fibrine during the 
stage in which venesection is employed, I have carefully examined more 
than twenty original published accounts of the fever in various localities, 
from Key West and Vera Cruz in the South, to Natchez and Rodney in 
the North, extending through a period of thirty years. Many of them are 
by physicians who made a liberal use of the lancet, but almost all are silent 
as to this appearance of the blood, while many declare that it is not sizy. 

We are not at liberty to suppose that if the blood has generally been so, 
the advocates for venesection would have failed to mention it. 

On the whole, then, we may conclude, as a true and permanent fact, that 
yellow fever does not in general generate sizy blood, in other words does not, 
like the phlegmasiae, increase the fibrinous element, and that a buffy coat is a 
rare exception [and probably due to incidental inflammation. — Ed.] 

But we cannot stop at this point. There is much reason for believing 
that the quantity of fibrine is diminished, even before the disease has reached 
its third stage, when no pathologist can doubt its impoverishment in respect 
of that element. The late Dr. Dodd* expressly says that this is the case, 
and Dr. Hulsef affirms the same thing ; which is still further manifested 
by the slowness of coagulation, the softness of the clot, and the early hemor- 
rhagic tendency, facts which are avouched by the majority of those who 
have spoken of the condition of the blood. 

* Western Jour, of the Med. and Phys. Soc. (Cincinnati) vol. v. 
f Maryl. Med. and Surg. Jour. vol. ii. 



INTERIOR VALLEY OF NORTH AMERICA. 317 

As a further change in the constitution of the blood, Dr. Dodd and Dr. 
Hulse, confirming the observation of Dr. Stevens, affirm that this fluid is 
deficient in saline ingredients, to which deficiency its dark color is in part at 
least to be ascribed. I was assured many years since by the former of these 
gentlemen, that he had verified this fact by experiments, which however are 
not published in the paper to which I have referred. 

If such be the condition of the blood in the earlier stages of the fever 
it must be aggravated in the latter; when its coagulability is nearly 
destroyed, and its color often a deep black. 

Hemorrhages. — To this condition of the blood, taken in connection with 
a certain degree of softening and relaxation of the solids, of which post- 
mortem inspections assure us, we may ascribe the hemorrhages so often pre- 
sent in this fever. They are what the theory of a loss of fibrine would lead 
us to expect, and may therefore logically be cited as proofs of the correctness 
of the doctrine. In the stage of excitement they would not occur if the dis- 
ease were a true phlegmasia, for then the congestions would be of a real 
inflammatory character, and the abundance of fibrine consequent on the dis- 
ease would prevent extravasation. These early hemorrhages, in fact, at once 
indicate a diminution of that element, and the absence of true inflammation 
in the tissues which are engorged, and which are relieved by the flow of 
blood. In these cases, vascular congestion and the vis-a-tergo of the heart, 
may be regarded as the exciting causes j a deficiency of fibrine as the pre- 
disposing cause of the extravasation. In the more advanced stages, the 
condition of the blood, and the incipient decomposition of the tissues, are 
the combined causes of the general and copious discharges of black blood ; 
which may sometimes give topical relief, but are the signs of serious 
lesion, in both the solids and fluids. 

Black Vomit. — What has been stated relative to the pathological 
anatomy of the liver, with its gall-bladder and efferent ducts, demonstrates 
what has been long believed, that the peculiar fluid called black vomit, is not 
a secretion from that organ, nor an altered state of the bile. It is in fact but 
altered blood, and would have no existence, but for the hemorrhages which 
have been described. Its well-known seat is the stomach and small intestines, 
but especially the former. Of its appearance, Dr. Harrison* gives us the 
following account : — 

" One of the most striking traits of yellow fever is the occurrence of black 
vomit. It has been correctly described as resembling coffee-grounds in a thin 
solution of gum Arabic, or infusion of flax-seed. But it varies greatly as 
to color. Sometimes we can see but a few striae mixed with the flocculent 
gray matter already spoken of. These striae are most apt to be found on the 
sides of the basin. In an hour or so, the fluid ejected from the stomach becomes 
darker, on account of their increase. Sometimes, instead of the coffee-grounds 

* New Orleans Medical Journal, vol. ii. p. 147. 



318 THE PRINCIPAL DISEASES OF THE 

appearance, the fluid thrown up approaches in color that of venous blood. 
In some cases, the vomit can be distinguished in nothing from blood in an 
uncoagulated, dissolved state. In short, between decidedly-formed black 
vomit and blood, there are numberless shades ; they run into each other by 
imperceptible degrees, and the distinctions that have been made by some 
authors in the appearances of the matter ejected from the stomach are al- 
together artificial. 

" In the quantity thrown up, there is also great difference in different cases. 
Some throw up enormous quantities ; others die after having ejected but a few 
strige." 

This description corresponds with those given me by many other physi- 
cians. It is composed, Dr. Harrison adds, "of solid particles held in 
suspension by the liquid, since they may be separated by filtration." 

It is a well-known fact, that black vomit may be closely imitated by adding 
muriatic acid and mucilage of gum Arabic to common blood. Dr. Harrison 
has published the details of an experiment of this kind, and numerous phy- 
sicians have given me unpublished statements of the same sort. 

The elements of the black vomit of yellow fever, then, are blood and the 
acid secretions of the stomach. To the formation of the compound, the loss 
of the saline ingredients of the blood may, negatively, contribute, by favor- 
ing a higher degree of acidity in the gastric juice; and hence may perhaps 
be explained the fatal indication afforded by the ejection of this fluid. It 
is a sign that the blood is in* such a condition as will probably be followed 
by death. It is uncertain whether the blood is acted upon by the acid agent 
in the parietes or in the cavity of the stomach. The coagulating quality of 
rennet, or the dried stomach of the calf, when steeped in milk, would favor 
the opinion that the blood of the stomach may be changed into black vomit 
as it passes through the parietes of the organ : if not, the mingling and 
change take place in its cavity. 

In whichever of these two modes the combination takes place, black vomit 
may be regarded as a melanotic fluid, identical (when we allow for the pre- 
vious changes in the blood), with the products obtained by Dr. Carswell,* 
in his interesting experiments on the influence of the gastric juice on blood. 

Some of our physicians have seen a fluid resembling black vomit dis- 
charged from the bladder. May not a superabundant acid, lithic, purpuric, 
or lactic, have in these cases been secreted by the kidneys, and'served as 
one of the elements of the black discharge ? 

* Elementary Forms of Disease. Also, Cyclopaedia of Practical Medicine, Art. Melanosis. 



INTERIOR VALLEY OF NORTH AMERICA. 319 



CHAPTER IX. 

PATHOLOGY. 

After the ample detail of pathological facts in the preceding chapter, I 
do not propose to devote much time to pathological speculations. 

1. The definite character of the symptoms, stages, and lesions of yellow 
fever prove it a specific disease, which extends to the functions generally, 
and leaves its vestiges, unequally, in all the organs; it is therefore the pro- 
duct of a particular remote cause. 

2. On what part of the body this cause exerts itself is unknown. If not 
absorbed into the blood by the skin or lungs, its impress must be made on 
one or both of those tissues. If absorbed, it may modify the constitution of 
the blood, and at the same time, make a morbid impression on the internal 
parietes of the vessels. In either case, it acts like every other agent, in 
virtue of a vital susceptibility in the tissues, and transforms their functions 
from a normal to an abnormal condition, which manifests itself by the 
phenomena of the forming or first stage of the fever. If we interrogate 
these, to learn which organ is first affected, we obtain no satisfactory answer; 
for while one seems to take precedence, in this case, another has that unde- 
sirable eminence in that, and another still in a third. In fact the perver- 
sion or disturbance of the functions is as extensive, and, relatively to each 
other, as great in the first, as the last stage of the disease, in many cases 
greater. It is impossible, then, to assign a particular organ, in which the 
primary morbid action is originated, and whence it is radiated sympatheti- 
cally throughout the system; indeed many of our physicians have observed 
that the organs, in certain very dangerous cases, do not seem to sympathize 
with each other, a fact which of itself indicates a constitutional lesion, for 
the sufferings of an organ would of necessity be felt by others, if the disease 
were local, that is, if the function of association on which all sympathy de- 
pends were not already impaired. 

3. This constitutional lesion — this perturbation of the organism (distur- 
bance of the functions), generally constitutes the fever, the type of which 
is expressed by the symptoms, while its effects are displayed in the ana- 
tomical derangements, solid and fluid, which have been presented. Both 
the symptoms and the lesions of structure demonstrate, that while the whole 
body is invaded, all parts are not equally affected ; nor is the mode of affec- 
tion the same in all. Let us devote a moment to this diversity. 

4. In some cases the enervating impress of the remote cause is so deci- 
sive, that no effective reaction takes place, and the forming and closing 
stages are brought into immediate sequence, the lesions of the third stage 
being formed without the intervention of the excitement which characterizes 



320 THE PRINCIPAL DISEASES OF THE 

the second, though not without the visceral congestions, which are insepa- 
rable from the disease. 

5. In other cases this reaction is prompt and so intense as not only to 
exhaust the vital forces, and thus at length leave the patient in a state of 
hopeless exhaustion, but to convert the simple congestions of the tissues into 
secondary or consequential inflammations, productive of lesions of structure 
not essentially different perhaps from those of primary inflammation. To 
these congestions, and the powerful action of the heart, we may in part 
ascribe the hemorrhages of this stage. The danger from these congestions, 
when they are equal in degree, is of course greater in proportion as the 
organ or tissue in which they are seated, is of more commanding importance 
in the economy. Those of the stomach, duodenum, brain, spinal cord, and 
great sympathetic, are most to be dreaded. 

6. The special function of the liver is impaired or suspended, whereby 
the elements of the bile, abundant in quantity from the influence of the 
preceding heat of summer, are chiefly retained in the blood, to color the 
tissues, and still further to deteriorate their functions. This impairment gene- 
rally exists from the beginning. 

7. At a later period, the kidneys fail, and the fate of the patient is often 
hastened by the retention in the blood of the elements of their excretion. 

8. A suspended state of the cutaneous secretion contributes though in 
a lesser degree to the same result. The favorable termination of cases in 
which the functions of the skin are not deeply impaired, must not be as- 
cribed to that condition, which is but a sign of a milder disease, or at most 
an evidence that the blood of the body has a greater exterior flow, and 
consequently the internal hyperemias are less. 

9. But it is not to the vital properties of the solids, their state of co- 
hesion, the congestions which form in them, nor the retention of the ele- 
ments of the excretions in the blood, alone or combined, that we must look 
for the whole danger, but add to them the deteriorated condition of the 
blood itself. 

In the present state of our knowledge of the mysterious relations between 
the blood and the solids which it penetrates, it would be futile to attempt a 
decision of the question which is first affected in this fever. Although 
some of our physicians believe with Dr. Stevens, that the lesion of compo- 
sition in that fluid precedes the lesions of the functions of the solids, the 
suddenness of the attack in many instances serves to indicate that the latter are 
primarily affected. However this may be, and whatever part a deterioration 
of the blood may play in the beginning and early periods of the fever, 
there can be no doubt of its sinister influences in the more advanced stages. 

First. Its reaction on the solids cannot be otherwise than pernicious. 
When the high febrile excitement of the second stage has subsided, one 
cause of exhaustion and death may be the contact of this blood with the 



INTERIOR VALLEY OF NORTH AMERICA. 321 

solids, throughout all the vital organs where it stagnates or circulates lan- 
guidly. 

Second. Its condition is unfavorable to a restoration of the secretions to 
a healthy condition. 

Third. As we have already seen, it favors those passive hemorrhages, 
which when they take place into the tissues, tend still further to their 
decomposition ; and when they occur on the tegumentary surfaces increase 
the exhaustion and collapse. 



CHAPTER X. 

TREATMENT. 



SECTION I. 

SELF-LIMITATION — PREVENTION. 

Self-Limitation. — Under every variety of treatment or no treatment, 
the febrile excitement in yellow fever, has a quasi definite duration. It 
cannot in this respect be put in the same level with the hot stage of erup- 
tive fever in small-pox and measles; but once established, no method hitherto 
pursued has been found to arrest it, though it may be moderated. On 
the other hand, under every method, and in the absence of all treatment, it 
will not run beyond three or four days, when it is succeeded by the third 
stage. The exceptions to this remark are but few, and depend in all pro- 
bability, upon the decisive establishment and reactive influence of inflamma- 
tion in some important organ ; constituting a case analogous to that of the 
conversion of an intermittent into a remittent or continued fever, from some 
incidental visceral inflammation. It appears then that a character of self- 
limitation belongs to yellow fever, and of course many cases would terminate 
favorably if nothing were done, as others end fatally under the most vigor- 
ous treatment; all of which is also eminently true of scarlatina. Of such 
a disease it may be said that the object is more the preservation of life than 
the arrest or cure of the fever. 

In this (imperfect) principle of self-limitation, we may, perhaps, find one 
of the sources of that variety in the treatment of yellow fever, which its 
therapeutic history presents — methods, in some degree, the most opposite, 
being equally lauded for their efficacy, when in fact the disease expired by 
its own limitation. 

Prevention. — This subject is not unconnected with the last. If yellow 
fever have a self-iimited character, can it be prevented in those who are ex- 

VOL. II. 21 



322 THE PRINCIPAL DISEASES OF THE 

posed to its remote cause ? I would say, that the possibility of successful 
prevention is inversely to the character of self-limitation, and therefore, that 
although more may be done to avert attacks of yellow fever than small-pox, 
still the prophylaxis of the disease is by no means very practicable ; and 
experience, in this case, verifies the decisions of theory. In certain seasons, 
emigrants from the North will enjoy an exemption from the fever in Mobile 
and New Orleans, without observing any particular course of regimen, or 
resorting to medicines of any kind, but the next year when the disease 
happens to prevail, they may be attacked, notwithstanding every precaution. 
It is true, as we have already seen, when speaking of exciting causes, that 
some one of them seems, in many instances, to have invited the attack, and 
they ought to be carefully avoided, but it is equally true, that attacks are 
incessantly experienced, notwithstanding such avoidance. In short, no im- 
migrant from a higher latitude can hope to escape an attack, although it 
may not always happen in the first epidemic he encounters. Uncertain, 
however, as all known means of prevention may be, it is proper to enumerate 
them. They are as follows: — 

1st. Avoid carefully every exciting cause. 2d. Let the plethoric occa- 
sionally lose blood, especially under any sense of fulness or pain in the head. 
3d. Keep the bowels regular with mild mercurial laxatives. 4th. Under 
any feeling of indisposition, let the patient lie by, and after proper alvine 
evacuation, promote the functions of the skin with alkaline'^diaphoretics and 
diluents. 



SECTION II. 

REMEDIES FOR THE FIRST AND SECOND STAGES. 

Diversities and Contradictions. — It would require a volume to pre- 
sent all the methods of treatment which the physicians in different places 
and seasons have pursued in this fever, a sufficient proof that it is not 
decidedly under the control of any. This untractableness is, then, one 
source of contrariety of treatment. A second, is the unquestionable differ- 
ence of type or nature which the fever presents at different times. A third 
is the various, and to some extent, conflicting theories of its nature, formed 
by different physicians ; a fourth, is preconceived opinion as to the powers 
and effects of different remedial agents. In proceeding to discuss its treat- 
ment under the advantage of being equally uncommitted to every method, 
and the disadvantages of never having witnessed the effects of any, I shall, 
as far as possible, unite the philosophical with the historical ; and endeavor 
to investigate the grounds of success and failure in connection with the testi- 
mony which different practitioners have borne to them. 

1. Bloodletting. — Whether we refer to the decisive influence of this re- 
medy, to the universality of its employment, or to the stage of the disease 
in which it should be resorted to, it deserves our first notice. 



INTERIOR VALLEY OE NORTH AMERICA. 323 

The benefits derivable from it may be referred to two heads. 

1. In the stage of prostration, at the beginning of tbe fever, it may some- 
times favor reaction, as it does in certain cases of intermittent fever. 

2. When reaction has taken place, it reduces the force of the heart; dimi- 
nishes internal congestions, arrests their change into true inflammations, 
or moderates them if established, favors the restoration of the suspended 
secretions; and increases the susceptibility of the system to the action of 
medicines. 

1. In ordinary cases, reaction occurs spontaneously. It is when the 
disease is marked by a malignant or highly congestive character, under a 
powerful and withering impress of the remote cause, when the forces of 
the system rally slowly and imperfectly, that venesection has been employed 
as a means of promoting reaction, or of preserving the internal organs from 
the effects of congestion until reaction shall spontaneously take place. Of 
its employment for this purpose, Dr. Cartwright* has spoken in terms 
of decided disapprobation. In his numerous trials, he seems never to have 
seen it followed by reaction, and in several instances, a reaction which had 
begun was arrested, and a state of alarming debility induced. Dr. Dodd,"|* 
however, in cases in which reaction took place slowly and the depression 
was great, saw the loss of from one to two ounces of blood every hour or 
two followed by the happiest results. It must be admitted, I think that in 
these cases, the bleedings produced but little effect. 

I do not find, either in the published accounts or in my MS. notes of 
the experience of a great number of physicians, any other than these limited 
records of experience on this subject, from which we may conclude that 
venesection has not often been resorted to as a means of promoting reaction. 

2. Let us turn our attention, then, to its employment after reaction has 
taken place. As in some epidemics this occurs much more slowly and 
feebly than in others, and never runs very high, the time when bloodletting 
should be employed and the extent to which it can be carried, vary from 
an early and liberal, to a total omission of that remedy. Dr. Cartwright has 
ably pointed out this ataxic reaction, and cited cases to prove that, if blood- 
letting be not deferred until reaction is established throughout the organism, 
it may arrest the efforts of nature and throw the patient back into the state 
of enervation from which he was emerging ; whereas if it had been post- 
poned a few hours decided advantage would have followed its use. Still, as 
already intimated, there are cases every season in which the excitement 
never becomes so developed as to permit a resort to this remedy ; and ac- 
cording to the observations of many physicians, even entire epidemics are 
of this character. 

It is certainly desirable to know by the symptoms when the lancet may 
or may not be employed. 

* Amer. Med. Rec. vol. ix. Epidemic of 1823. t Western Journal (Cincinnati), vol. v. 



324 THE PRINCIPAL DISEASES OF THE 

Dr. Dodd says if the vessels of the conjunctiva are filled with dark blood, 
the eye sad and watery, the tongue white and dry, or raw like beef, and the 
pulse at the same time small, blood should not be drawn either at the com- 
mencement or any subsequent stage of the disease. Dr. Harrison says 
when the patient is of a nervous temperament, or feeble constitution, when 
any ataxic symptoms supervene, such as nervous delirium, &c; the lancet 
should not be thought of. Dr. Morgan intimates that when there is little 
vascular excitement, much torpor both mental and physical, and great irri- 
tability of stomach, venesection does not succeed. Dr. Rushton* informs me 
that in cases attended with but little heat, a pulse often not above 90, irrita- 
bility of stomach and apathy of mind without delirium, the patient answering 
that he is better, the lancet is inadmissible. Drs. Williams and Andrews 
have published,")" that when the fever prevailed in Rodney, the pulse in 
some cases was soft and compressible, in others tumultuous, bounding, but 
gaseous, and easily arrested. Such cases would not bear the lancet. Dr. 
Perlee, in his account of the epidemics of 1817 and 1819, at Natchez,J says, 
that the necessity for venesection did not exist. In some patients with 
plethoric habits it was used, but without any good effect. There was none 
of that mitigation of suffering which this powerful remedy produces when 
appropriately employed. 

The experienced Dr. Hulse,§ declares that in some epidemics the de- 
pressed vitality of the organic nerves is such as to occasion a languid cir- 
culation of the blood, in which cases, venesection hastens a fatal termi- 
nation. " This," continues he, " was the character of the epidemic in 
Pensacola, in 1839, when in private practice I treated one hundred and 
forty-six cases, almost invariably without bloodletting, with a loss of only 
six." 

Dr. Buegnot|| says, of one form of yellow fever, " the face is pale, the 
pulse is soft and a little frequent," in which case, only small revulsive 
bleedings are advisable. 

To this testimony we may add that of Dr. Lewis of Mobile, who says, 
" In these years (1842, 3, and 4), I did not meet with a patient, &c. (see 
page 424), whose pulse was hardy tense, contracted, or wiry ; even in cases 
where it was 115, it was invariably gaseous and bubbling. Coupling this 
state of the pulse with the certainty that it would in a few hours sink 
to 80, 70, and even 60, after which collapse with a train of debilitating 
phenomena must ensue, none could be found so hardy as to draw blood 
from a vein. The operation under such circumstances as these, would have 
been entitled to a distinction, which none but a Sangrado could have en- 
vied." 

Dr. Fearn, of the same city, found bloodletting ineffectual and injurious 

* MS. Mem. f Maryland Med. and Surg. Jour. vol. ii. 

% Phil. Jour. vol. iii. § New Or. Med. Jour. vol. i. 

II New Orleans Med. Jour. vol. i. p. 18. 



INTERIOR VALLEY OF NORTH AMERICA. 325 

in 1842 ; and Drs. Levert, Nott, Lopez, M'Nelly, and Woodcock of the 
same place, have informed me, that the epidemic of 1843, with very few 
exceptions, absolutely forbade bloodletting. 

Its prominent symptoms, as narrated to me by Dr. Nott, were a slight 
chill, or none ; pain in the back and muscles, often violent ; but little gas- 
tric irritability in the beginning j bowels generally regular, and the first 
evacuations from medicines commonly healthy ; the heat of the surface 
never very great; the pulse not commonly above 110 or 115, in force 
never above but often below the standard of health j flushing of the face 
and eyes, moderate ; thirst not intense, often none ; tongue often perfectly 
natural; intellectual functions sound, but the feelings and expression of coun- 
tenance, anxious. 

These authorities although they very imperfectly acquaint us with the 
diagnosis of those cases or epidemics in which the lancet is contraindicated, 
are sufficient to establish the important fact that such do exist, and that 
bloodletting is not always required or even safe. 

Let us inquire, secondly, what symptoms characterize those individual 
cases as well as epidemics, which demand venesection, and also the extent 
to which it should be carried. 

Dr. Cartwright* remarks, of the Natchez epidemic of 1823, that when 
the heat of the whole surface is excessively increased, the pulse full and 
strong, the patient lying naked, and calling on the attendants to fan him, 
and to give him cold water, we may bleed fearlessly and successfully. A 
small quantity will not reduce this violent reaction. It may be taken away 
by quarts. Such bleedings moderate the heat, alleviate the pain, soften the 
pulse, revive the suspended secretions, and render the system susceptible to 
the impress of medicines. 

In the epidemic of 1825 of the same city, Dr. Merrill")" found that when 
there was a full strong pulse, with acute pains in the head, back, and limbs, 
a bleeding of from one to two pints, the patient being kept recumbent, was 
attended with the very best effects. He often found it necessary to repeat 
the operation once or twice on successive days. All cases, however, were 
not of this acute kind, for in some, collapse succeeded to free bleeding. 

Dr. DoddJ assigns the following assemblage of symptoms as demanding 
the lancet : a full and hard pulse, a red and engorged eye with a glaring ex- 
pression, a severe and deep-seated headache, a furred tongue, hot and rough 
skin, and laborious respiration. He often drew fifty ounces at once, and 
although greatly preferring to do it on the first day of the fever, often re- 
sorted to it on the third. He made a large orifice, and suffered the blood 
to flow until it changed from a dark to a bright red, when he arrested it, 
from having discovered that any further detraction after the appearance of 
that hue greatly debilitated and injured the patient. 

* Am. Med. Rec. vol. ix. f N. A. Med. and Surg. Jour. {West. Jour. vol. v. 



326 THE PRINCIPAL DISEASES OF THE 

In the fever of Key West, 1824, Dr. Ticknor* whenever he found a tense 
and wiry pulse, however small, accompanied with tenderness, burning and 
oppression in the epigastrium, violent headache with red protuberant eyes, 
a tumid, flushed countenance, a hot, florid, and dry skin, had immediate re- 
course to the lancet. Sitting his patient up, he generally found the loss of 
from sixteen to twenty ounces productive of the relief which he sought to 
procure j but a revival of morbid excitement often rendered a repetition of 
the operation necessary, he rarely, 'however, observed any advantage and 
sometimes an injury from employing it after the second day of the fever. 
Among the good effects of this practice, was the facility with which cathartic 
medicines subsequently operated. 

Dr. Morgan, f in the same epidemic, found that the officers of the navy who 
lived on a nourishing and generous diet, were greatly benefited by copious 
venesection, while the seamen who lived on salt-meat and sea-biscuit, and 
underwent great fatigue, did not bear that kind of treatment. 

Dr. Barrington in his account of the fever in our national ships in the 
G-ulf of Mexico, 1828, '29, and '30, J says, that of the few bled on board 
the Hornet, where the mortality was great, every one recovered. On the 
Grampus, when the attack was violent and reaction considerable, with a full 
active pulse, and severe headache, which happened in a majority of instances, 
he bled until a decided impression was made on the system. For this 
purpose it was generally necessary to draw from twenty-four to thirty-two 
ounces, and sometimes more. There was no death on the Grampus, after 
this practice was adopted. On the Peacock, however, the success was less. 
Out of ten reported cases, eight were bled from ten to forty ounces, of whom 
one half only recovered. Two who were not bled died. 

Dr. Smith, in the fever at Gralveston, 1839, § when called to a patient, if 
the excitement was fairly developed, immediately raised him to a sitting 
posture, and bled him till slight faintness or a mitigation of the pains was 
produced, which generally required from twelve to twenty ounces. He 
seldom repeated the operation, and supposes he did not obtain from it all 
the benefits it might have conferred. 

Dr. Huestis,|| who treated the fever from 1809 to 1812, in New Orleans 
and in the army, informs us that by bloodletting to the extent of sixteen or 
twenty ounces, he softened the pulse, abated the heat and pain, diminished 
the redness of the eyes, relieved the general distress, softened the skin, and 
sometimes brought on a general perspiration. He often repeated it in twelve 
or eighteen hours, and never had occasion to regret its employment, except 
when it was deferred to the third or fourth day, when it proved injurious. 

In 1822, at Pensacola, Dr. M'Mahon^f observed before the 9th of October 
the fever required a free and liberal use of the lancet, but after that time 

* N. A. Med. and Surg. Jour. vol. iv. t Phil Jour. J Am. Jour. vol. 12. 

§ An Account, p. 25. || Topography and Diseases of Louisiana, 1817, p. 115. 

tf Medical Stat, of the United States Army, p. 40. 



INTERIOR VALLEY OF NORTH AMERICA. 327 

it was inadmissible, and the "strongest stimulants were imperiously de- 
manded." 

In New Orleans, 1832, Dr. Lawson,* now Surgeon-General, found the fever 
u manifestly to require one or more full bleedings." 

In the same city, Dr. Marshalf opened a vein, and then plunged the arm 
into warm water, suffering the blood to flow till the headache ceased, repeat- 
ing the operation when the pain returned; a practice which, according to 
Dr. Thomas, produced the happiest results. 

Dr. Cronkrite, in the same city, 1 829, t employed early and copious bleed- 
ing with the best effects. When thus employed, it mitigated every symp- 
tom, but if postponed, it did harm, and when carried only to the extent of 
eight or ten ounces, did no good. 

In the epidemic of 1833, Dr. Barton§ found bloodletting universally re- 
quired. Keeping his patient in a horizontal posture, he drew blood, like 
Dr. Marshall, till the pain ceased, and repeated the operation when it re- 
turned. He rarely bled, however, more than twice from the arm, preferring, 
after that, cups or leeches. He speaks in the highest terms of the good 
effects of this depletion, which was sometimes carried to the extent of ninety 
ounces. 

In the epidemic of 1841, according to Dr. Thomas,|| although much sul- 
phate of quinine was administered, liberal bleeding was first employed. 

The last printed authority which I shall cite, is that of Dr. Luzenberg, 
of New Orleans, and the historian of his experience, Dr. Buegnot.^f Accord- 
ing to the latter, Dr. Luzenberg has been accustomed in nearly all cases 
of yellow fever since 1829, to resort to copious and repeated bleedings. In 
all congestive, phlegmonous cases, he carries the bleeding to syncope, and 
repeats it every six or eight hours, as long as the excitement continues to 
rise. He frequently carries the first to full syncope, and the subsequent to 
partial. Of course the earlier in the disease the better; but both the gen- 
tlemen testify that on the third and fourth day, and even in the midst of 
those hemorrhages which have been called passive, it is the best thing that 
can be done. After they have laid aside the lancet, they continue depletion 
by cups or leeches, and on the whole, although they do not absolutely advise 
bleeding in every case, and in all stages, and to the exclusion of everything 
else, in yellow fever, they carry this remedy further, and place on it a more 
exclusive reliance, than any other physicians of the Valley. 

I shall not extend the quotations in favor of bleeding to niy manuscript 
authorities, as they would not materially change the aspect of our narrative. 

It will be seen that the testimony here embodied is drawn from different 
latitudes, from Key West to Natchez, from villages and the city, from civil 
life and from the experience of the Army and Navy ; it therefore presents 

* Med. Stat, of the U. S. Army, p. 267. f Essai sur la Fiev. Jaune, par le Docteur Thomas, p. 96. 

+ Western Journal, vol. iii. § American Journal, vol. xv. 

U Relat. de l'Epid. de Fiev. Jaune, p. 17. f New Orleans Med. Journal, vol. i. 



328 THE PRINCIPAL DISEASES OF THE 

all tlie variety of data we could desire, and the conclusion must be, that, on 
the whole, yellow fever is a disease which has been met by the lancet, and 
that a majority of our physicians regard it as a sine qua non in the case. 
If, however, we inquire for evidence of its power to stop the disease in the 
midst of its career, as it might a pleurisy or peritonitis from cold, or a gas- 
tritis from an acridj poison, we shall be disappointed ; if we seek for proof 
that it can preclude entirely that pathological condition which follows the 
decline of the stage of excitement, and is characterized by a morbid con- 
stitution of the blood, passive hemorrhages, suspended secretion of urine, 
and the occurrence of black vomit, we shall find it inadequate, though it 
may greatly abate the danger of that stage, and favor the safe passage of 
the patient through it. Bloodletting, then, is not a specific for yellow fever, 
not the remedy, but still a remedy j not applicable to all, but yet to many 
cases ; improper in some epidemics, demanded in others ; not to be resorted 
to as a matter of course, but with discrimination ) chiefly beneficial in the 
early, often pernicious in the latter stages ; not employed to cure the dis- 
ease, but to produce the mitigation of excitement, and create a predisposition 
for the beneficial effect of other remedies, which were recognized as its 
legitimate effects in the proposition affixed to this article, and through these 
effects, combined with the effects of other measures, causing the fever to 
run its course without destroying life. 

Local Bleeding. — Cups or leeches have been still more generally em- 
ployed, than the lancet. Almost every physician who has published, or 
communicated to me the results of his experience, has enumerated them 
among his remedies, and very generally with approbation. The discrepancy 
of opinion and practice which prevail as to venesection, has not arisen on 
the subject of topical bleeding. In certain epidemics and in particular 
cases modified by the constitution of the patient forbidding venesection to 
be employed, the local abstraction of blood has still been practised with ad- 
vantage, or at least with safety. But, it is in cases which have required 
venesection, and after that had been carried as far as the physician deemed 
judicious, that cups or leeches have been most employed. The parts to 
which they have been generally applied are the epigastrium, the temples, the 
mastoid regions, the nuchse, the back, and the loins, with a view of influ- 
encing the condition of the stomach, duodenum, liver, and splanchnic nerves, 
the brain and spinal cord, and the kidneys. That they have often done 
this most beneficially to the patient is undeniable. 

By most of our physicians this mode of bleeding has been regarded as 
altogether subordinate to that with the lancet, and in all violent cases ineffi- 
cient without previous venesection. Those among them, however, who, 
adopting the doctrines of Broussais, have regarded yellow fever, as a gastro- 
enteritis raising a general fever, have consistently believed that local bleed- 
ing from the epigastrium might in general be made sufficient, and at all 



INTERIOR VALLEY OF NORTH AMERICA. 329 

events could not be superseded by the lancet. The results of this prac- 
tice deserve to be stated. 

In his account of the New Orleans epidemic of 1833,* Dr. Barton in- 
forms us that local bleeding was among the remedies from which he found 
the greatest advantage ; in most cases, however, it was preceded by copious 
venesection. A majority of his patients were cupped or leeched once only, 
a large number twice, and a few from four to eight times. In all, the greatest 
relief from topical distress followed the operation. In the same paper we 
are informed that he had made this a principal remedy for the preceding 
five years, and had found it more successful than any other mode. 

In the same epidemic,f Dr. Harris placed still greater reliance on this 
remedy. Of eighty cases treated by him in this way but four proved fatal. 
He has published in detail twenty cases, of which two ended in death. Of 
leeches alone the greatest number applied in a single case was sixty-six — 
of cups alone twenty-six; in a number of cases both were employed, and 
an average for the whole would be about twenty-one leeches and eleven 
cups. They were generally applied to the epigastric, hypochondriac, and 
lumbar regions, the back of the neck, and behind the ears. The quantity 
of blood thus drawn, was evidently much less than would have been lost 
in an equal number of cases by the lancet in the hands of one who practised 
venesection in this fever ; and the constitutional effects were corresponding. 
In no instance is a tendency to syncope mentioned ; but in nearly all the 
local sufferings in parts over which the cups or leeches were applied, were 
immediately mitigated or removed. It would appear then that local bleed- 
ing vigorously employed, may be made a substitute for venesection. In 
many cases it may even be preferable; but, for the same reason, in others 
it is less to be relied upon, unless, indeed, it be carried so far as to produce a 
constitutional, in addition to a local effect, when perhaps it would be quite 
as well to rely on the lancet. In private practice during an epidemic, the 
difficulties and expense attendant on adequate cupping and leeching must 
always constitute drawbacks on the success of the practice ; which is there- 
fore not likely to supersede, but rather to continue subordinate and auxiliary 
to venesection. In hospital practice, it may to some extent be otherwise, 
as the time and means admit of a larger abstraction of blood from particular 
parts, and many patients are brought in, when the disease is too far advanced 
to permit venesection. It must be borne in mind, however, that in the 
latter periods of the fe^er the bleeding from leech-bites cannot always be 
restrained, and has sometimes proved dangerously exhausting to the patient. 
This was emphatically mentioned to me by Dr. Balfour of Yicksburg, and 
Dr. Meux of New Orleans. " 

I have not met with much evidence relative to dry cupping, but in anemic 
constitutions where mere sanguineous revulsion is required it might be found 
beneficial. 

* American Journal, vol. xv. t Ibid. vol. xiv. 



330 THE PRINCIPAL DISEASES OF THE 

Emetics. — In the fever of Natchez in 1823, and of that city and Wash- 
ington in 1825, Dr. Cartwright, Dr. M'Pheters, and some other physicians, 
found full doses of tartar emetic eminently beneficial in bringing on reaction, 
and equalizing it throughout the system. In cases attended with great cold- 
ness and depression, they did not succeed. When given after reaction was 
established, their effects were equivocal, and in the third stage of the disease, 
injurious. In 1837-39, Dr. C. used them, but found their effects less bene- 
ficial. In the same disease, Dr. Merrill, in the early stages, encouraged the 
disposition to vomit with warm water, and found it beneficial, but did not 
administer emetics. In the preceding epidemics of 1817 and '19, Dr. Perlee 
did not employ them ; nor did Dr. Monette in that of Washington in 1825. 
Dr. Branch of the same town, however, gave tartar emetic and Epsom salts, 
as he informed me, with advantage. Latterly, the physicians of Natchez do 
not appear to have employed emetics. 

Of the physicians of Vicksburg, I am acquainted with the practice of 
Drs. Hicks, Balfour, Harper, and Anderson (now of St. Louis), and none of 
them employ emetics. 

In Rodney, Drs. Williams and Andrews administered emetics early in the 
disease in a number of cases, but they did not promote reaction, and often 
produced much gastric distress. 

In Woodville, Dr. Kilpatrick eschewed their use, on account of the irri- 
tability of the stomach. 

At Key West, in the early stage of the fever, when the stomach was loaded, 
and there was a sense of oppression, with nausea, Dr. Ticknor gave them 
with essential benefit. They promoted a favorable reaction, and often gave 
an early and salutary determination to the skin. When he had reason to 
believe there was gastric inflammation he withheld them. Dr. Morgan, in 
the same epidemic, administered an emeto-cathartic in all cases in which the 
disease suddenly supervened on a full meal, and found it not only safe, but 
beneficial. 

In his account of the treatment of yellow fever through several epidemics 
at the Navy Yard, on board of ships, and in Pensacola, Dr. Hulse says 
nothing of emetics. 

Dr. Dodd, even as late as the third day of the fever, when the stomach had 
been irritable, without what he regarded as signs of inflammation, gave 
emetics of ipecac, and the sulphates of copper and zinc, with excellent 
effects. 

Dr. Lewis, in his incidental notices of the treatment of the fever in 
Mobile, says nothing of emetics. From Drs. Levert, Fearn, Nott, Ross, 
Harrison, and Kovaliski, I learned that they did not administer emetics. 
Dr. Woodcock, however, has given them, when the tongue was heavily 
furred and brown. 

At Galveston, Dr. Smith encouraged the early vomitings with tepid water, 
but never gave emetics. 



INTERIOR VALLEY OP NORTH AMERICA. 331 

At New Orleans, Drs. Cronkrite, Harris, and Barton, who have published 
their experience, did not use emetics ; but Dr. Harrison, in those who are 
seized immediately after a full meal, is accustomed to evacuate the stomach 
with ipecac. The French physicians, Drs. Thomas, Bahier, Fortin, Daret, 
and Martin, on behalf of the Societe 31edicale, are silent in regard to them, 
while Dr. Buegnot condemns them as pernicious, and says they are generally 
abandoned. In accordance with this remark, I may state, that in conversa- 
tion with Drs. Stone, Meux, Rushton, Campbell, Mackie, Jones, Kennedy, 
and Graham, of New Orleans, I learned that they do not employ emetics. 

Thus it may be received as a fact that emetics are not among the reme- 
dies for yellow fever, in the Valley of the Mississippi. A number of its 
physicians have tried and rejected them ; others I presume have never 
employed them. It is possible that to some extent their disuse may be 
ascribed to fashion, for it seems that in the years 1823, 4, and 5, Dr. 
Cartwright and Dr. Ticknor found them beneficial in many cases. Since 
that period the emetic practice in most of our diseases has been rapidly on 
the decline. I cannot but think that in the forming stage of the fever, when 
the stomach happens to be loaded with undigested food, or which sometimes 
happens, with bile, as is evinced by its spontaneous ejection, an emetic 
might be of service. There cannot then be any active inflammation to 
contraindicate its use. In very malignant cases, such as will not in any 
stage admit of bleeding, an emetic might promote reaction ; but adminis- 
tered in such a state of the system, it should be of a stimulating character. 

Cathartics. — About the year 1812, Dr. Huestis found an attention to the 
state of the bowels especially necessary. He used calomel and jalap, aided by 
Glauber's salts, cream of tartar, and injections. Large doses were required, 
when copious evacuations of a dark green or black color were produced. 
In 1817, and 19, Dr. Perlee gave ten grains of calomel every hour, till 
free evacuations were obtained, and speaks highly of the practice. In that of 
1823, Dr. Cartwright found cases which required the lancet, successfully 
treated with purgatives, and whenever they produced bilious discharges 
they proved especially beneficial; sometimes, however, they occasioned serous, 
mucous, or bloody discharges, then they were injurious. On the whole he 
preferred mild, to drastic cathartics. His time for administration was 
during the stage of excitement. In 1825, he frequently gave boluses of 
calomel, scammony, and aloes, and also resorted to croton oil and oil of tur- 
pentine. In the same epidemic, Dr. Merrill gave a scruple of calomel, fol- 
lowed by sulphate of magnesia, jalap, and cream of tartar, or castor oil ; 
or, in place of these, he administered pills of calomel, aloes, and colocynth. 
Dr. Monette in the same season purged freely with calomel and castor oil. 
About the same time Dr. Ticknor purged his patients copiously with scruple 
doses of calomel, which brought away an abundance of vitiated hepatic and 
intestinal secretions. In the treatment of the same fever Dr. Morgan gave 
calomel, sometimes combined with ipecac, and followed by Epsom salts, and 



332 THE PRINCIPAL DISEASES OF THE 

other saline cathartics, keeping up a brisk operation for two or three days, 
when his patients generally did well. In 1828, Dr. Cronkrite produced 
copious and repeated evacuations, by giving fifty or sixty grains of calomel, 
and following it up with castor oil or salts. 

About the same period, Dr. Dodd, after first opening the lower bowels 
with injections of sea-water, administered large doses of calomel and jalap, 
followed by sulphate of magnesia, or substituted for them pills of calomel, 
aloes, gamboge, tartar emetic, and croton oil. Such was the practice pur- 
sued previously to the year 1830. 

In 1833, Drs. Barton and Harris, governed by the ideas of Broussais, 
discarded calomel and all drastic cathartics, in place of which they adminis- 
tered an occasional dose of castor oil, and assisted its operation with large 
emollient and oleaginous injections. 

In the G-alveston fever of 1839, Dr. Smith, after the few first cases, aban- 
doned calomel as a purgative, and opened the bowels with an infusion of 
senna and rhubarb, which he preferred to every other cathartic. He occa- 
sionally assisted it with an injection. After the free operation of one dose 
of this medicine, he preferred to leave the bowels in a state of repose, and 
did not repeat it, at least till the next day, and then not in large doses. 

Dr. Hulse administers a scruple of calomel, to be followed by castor oil, 
and in some cases an injection. He lays much stress on early and free 
evacuation of the bowels, but this once effected, he aims at no more than a 
couple of discharges every twenty-four hours. He gives a caution against 
hypercatharsis, which may end in diarrhoea, with dangerous prostration. 

We learn from Dr. Lewis's paper, that he and his medical friends in Mobile 
are in the habit of exhibiting a small dose of calomel, or that medicine and 
rhubarb combined, followed by castor oil, salts and senna,, or sweet oil and 
fresh lime-juice, subsequently they maintain the action of the bowels with 
blue pill. What I learned from Dr. Fearn, Dr. Levert, Dr. Nott, Dr. Ross, 
and several other medical gentlemen of that city, corresponds with this 
statement. Several of them are in the practice of giving pills composed 
of equal parts of calomel and the blue mass ) some prefer calomel and the 
compound extract of colocynth ; some give blue mass, or that medicine com- 
bined with rhubarb and succeeded by oil. Whatever may be the means 
used, every physician aims at nothing more than gentle purging, and re- 
gards a drastic operation as injurious. 

In New Orleans, at this time, the practice is similar. Dr. Harrison has pub- 
lished a condemnation of drastics. He thinks it important to evacuate fully 
the existing contents of the bowels, by mild cathartics, after which it is suf- 
ficient to maintain the peristaltic function, which can generally be done 
with injections. Of cathartics he prefers blue pill, or calomel, in a small 
dose, followed in a few hours by castor oil or some saline laxative. From 
the numerous respectable physicians, quoted when speaking of emetics, I 



INTERIOR VALLEY OF NORTH AMERICA. 333 

learned that they all condemn active and continued purging, while they 
concur in the necessity of an early evacuation of the existing contents of 
the primce vice. To this end they administer small doses of calomel, blue 
mass, rhubarb, castor oil, and such like aperients, and promote their ope- 
ration by enemata, on which alone some of them place their chief re- 
liance. 

As to the French and Creole physicians, it is scarcely necessary to re- 
mark, that under all circumstances they employ only the gentlest laxatives 
and injections, almost without exception condemning the use of any 
mercurial preparation. Dr. Buegnot, in his paper already quoted, speaks 
however of free alvine evacuation with more approbation than his brethren 
generally ; admitting that before inflammation has established itself in the 
mucous membrane, the local depletion occasioned by cathartics may prove 
beneficial ; but that on the whole they are of doubtful propriety, and can 
only be employed in certain cases. 

It appears from all that has been said, that 25 or 30 years ago, active 
purging in our yellow fever, in imitation of that which according to Dr. 
Hush proved so eminently beneficial in Philadelphia, in 1793, was far more 
common than at present, or than it has been for the last 15 years. To 
what are we to ascribe this change of practice, a change which our phy- 
sicians believe is founded on experience ? Has the disease undergone a 
change in its character ? Have theories in medicine worked out a change 
in practice ? Or is it true that copious purging is not so injurious as we 
now suppose, and yet, that gentle purging, will give us all the benefit of 
the most violent? 1 am disposed to ascribe something to each of these 
influences. But without dwelling on the causes which have brought about 
the modification of a practice, let us inquire into its modus operandi, effects, 
and limitations. 

Of the early necessity of evacuating the contents of the stomach and 
bowels, which retained would prove a source of irritation, there can be no 
doubt; but in reference to this object, it is manifestly proper to use mild 
and unirritating means. It is sometimes said that the evacuation must be 
kept up with some activity throughout the disease, because of the reaccu- 
mulation of morbid secretions, but as the liver must necessarily be a chief 
source of these, and as many of the symptoms and pathological appearances 
indicate that organ to be commonly in a torpid condition, there would ap- 
pear to be less to remove than was once supposed. The mucous membrane 
and in many cases the liver also is in a state of congestion, and purgatives 
it is said will carry this off. Purgatives, however, can only remove intes- 
tinal and hepatic engorgement, by promoting secretion j and as they do 
not always produce that effect, they cannot always relieve the congestion of 
those parts. These medicines, however, produce revulsion from the brain 
and spinal cord, and in that way may save those organs from fatal hyper- 



334 THE PRINCIPAL DISEASES OP THE 

seniias, while they diminish the morbid excitement of the heart and vascu- 
lar system ) and on this effect no doubt much of their efficacy depends. 

Let us inquire into the injuries they may produce. 1st. In malignant 
cases, when the reaction of the system is feeble, they may exhaust too 
much ) and when there is a tendency to diarrhoea in connection with con- 
stitutional enervation this danger is still greater. 2d. If inflammation of 
the mucous membrane actually exist, they can scarcely fail to aggravate it 
if pushed very far; and, even when there is only simple congestion, it may 
be a question whether active or irritating cathartics may not transform it 
into inflammation. 3d. In proportion as they establish a drain from the 
mucous membrane they create a flux of blood towards it. They give to 
that fluid a centripetal direction. They invite a great deal into the viscera, 
which does not accumulate in them, simply because it is transformed into 
secreted fluids and then carried out of the system. Thus under their in- 
fluence the exterior parts of the body lose too much of the circulating fluid, 
and the skin fails in its functions, the internal organs meanwhile becoming 
the seats of irritation and fluxion. If a patient labored under an inflamma- 
tion of the brain, the eye, the skin, or a joint, from some common cause, 
copious purging might cure it by the combined influence of revulsion, deple- 
tion, and enfeeblement of the heart; but, as we have already seen, when 
speaking of venesection, yellow fever cannot be thus terminated, and there- 
fore such purging will not cure the fever. As a simple antiphlogistic 
measure, it has moreover this disadvantage, that the stomach, whether gas- 
tritis exist or not, is generally irritable, and purgatives are not only liable 
to be ejected, but they frequently increase that condition. 

The following, then, are the restrictions which theory imposes on the use 
of purgatives, and the rules which it suggests for their administration. 

1. Those which are least offensive to the stomach and least likely to irri- 
tate the bowels, should be chosen. 

2. When the reaction of the system is feeble, and when the excitement 
is declining, they should be exhibited sparingly. 

3. When the excitement runs high, copious bleeding should precede their 
operation if not their administration. 

4. Such as increase the secretions from the liver and the mucous mem- 
brane, should be preferred. 

5. When the head is greatly affected and the excitement of the system 
considerable, their operation may be pushed further than under other cir- 
cumstances. 

6. As a means of relieving the congestion of the abdominal viscera, not 
of producing revulsion from distant parts, their action should be moderate, 
otherwise, as we have seen, they will invite blood into those organs. 

7. As evacuants from the lower bowels, when costiveness exists in con- 
nection with an irritable stomach, injections should precede the administra- 
tion of purgatives. 



INTERIOR VALLEY OF NORTH AMERICA. 335 

Now it will be seen that the present mode of purgation does, in fact, 
conform to these restrictions, and that the argument a posteriori confirms 
the a priori. 

Calomel. — This medicine has a maintained its place as a cathartic, ever 
since those portions of the shores of the Gulf and Valley of the Missis- 
sippi in which yellow fever occurs, were ceded to the United States, and 
Anglo-American physicians began to practise in them. At the present 
time it is administered in doses incomparably smaller than it was thirty 
years ago ; but there is no reason to anticipate that it will fall out of the 
catalogue of cathartics employed in this fever. It was formerly, however, 
given for a different purpose, and to that we now turn. 

1. The obvious involvement of the hepatic in the disorder of the abdo- 
minal functions, and the generally admitted specific action of calomel upon 
the liver, suggested its liberal exhibition as a means of restoring, reducing, 
or regulating the functions of that gland, and to this end, aside from its 
cathartic effects, it was administered in large quantities. 

2. Regarded as an antiphlogistic alterant, it was given to produce specific 
constitutional effects, on the development of which, it was expected the fever 
would cease. 

As many other things were done in connection with this practice, and as 
the reports on different modes of treatment by our physicians are generally 
quite imperfect, it is not possible to institute a conclusive comparison 
between the mercurial and other methods. We must rely then on its general 
abandonment for the evidence that it was not successful. The objections to 
it are : — 1st. It generally fails to re-excite the functions of the liver. 2d. 
The stage of excitement is too short to permit the establishment of a con- 
stitutional effect. 3d. When that effect has been produced, it has not pre- 
vented the stage of collapse with its petechiae, passive hemorrhages, and 
black vomit; but in the opinion of some physicians with whom I have con- 
versed, seemed to aggravate them. That this is not altogether imaginary, 
may be inferred from the well-known injurious effects of calomel in scurvy, 
a disease in which the blood, as in the third stage of yellow fever, is deficient 
in fibrine. 4th. Those who have recovered under the constitutional impress 
of calomel, have often experienced a tedious convalescence, in connection with 
a vexatious ulceration of the mouth. 5th. By relying on calomel, other 
things of less equivocal value, have sometimes been neglected. 

I will not go into a citation of authorities in support of these objections, 
as the mercurial practice has at present so small a number of advocates ) but 
must not omit a reference to the paper of Dr. Barrington, already quoted. 
On one of our national ships, the Peacock, lying in Pensacola Bay in 1830, 
twenty-three cases of yellow fever occurred, of which fifteen were treated on 
the mercurial and eight on the non-mercurial plan. The results are as 
follows : — 



336 



THE PRINCIPAL DISEASES OP THE 



Of seven patients who were treated in the first method, — 



1 took of calomel 


, 5 


1 " 


a 


7 


1 " 


u 


10 


1 " 


a 


11 


1 *' 


a 


12 


1 ft 


(( 


13 


1 " 


cc 


15 



a 


22 


« 


c< 


28 


« 


« 


22 


it 


(< 


22 


c« 




22 
39 





All of these were salivated. 

Of seven who were treated on the non-mercurial plan, — 

2 were well and fit for duty in 11 days. 
1 was " " " 11 " 

1 « « « 12 » 

2 «< << << 27 " 
2 were " " " 19 " 
1 was " " " 20 " 

Of the nine fatal cases, eight were treated with mercury ; of whom five 
were salivated, or had the mouth affected. 

The remaining cases underwent a mixed plan of treatment. In some of 
them calomel was used, but not with the view of salivating ; these recovered 
in from sixteen to twenty-six days. 

Non-purgative Alkaline Salts. — The practice recommended by Dr. 
Stevens, founded on a discovery or supposed discovery — that in yellow 
fever, even from the period of its incubation, there is a deficiency in the 
saline ingredients of the serum of the blood, has not been followed by our 
physicians to a sufficient extent to ascertain its effects. Dr. Dodd, as far 
back as 1831, had verified this condition of the blood, but does not seem 
to have founded his practice upon it. He mentions two facts, however, 
which may be regarded as connected with it. 1st. He used small doses of 
neutral salts, as laxatives, with much benefit. 2d. He found voluminous 
injections of sea- water of great value, and believes that portions of them were 
absorbed from the rectum and colon. 

Previous to this, or to the suggestions of Dr. Stevens, a practice had been 
pursued by some of the French physicians of New Orleans, which, although 
its object was merely the evacuation of the bowels, deserves to be mentioned 
under this head. It was followed in 1819, and again in 1822, as we learn 
from Dr. Thomas, in his account of the fever in the latter year, p. 98. It 
is called the method of Goiffon, from an apothecary of that name, who in- 
troduced it from St. Domingo, where he had resided. It was followed, says 
Dr. Thomas, under many circumstances, with some advantage. The follow- 
ing is the formula : — 



INTERIOR VALLEY OF NORTH AMERICA. 337 

R. — Nitrate of Potash, ^ij. 

Sulphate of Soda, ----- gyj. 

Bitartrate of Potash, - - - - 9iij- 

Acetate of Potash, - xxiv. grs. 

Dissolve in a quart-bottleful of hot water. 

Of this solution, a wineglassful was given at intervals of one or two 
hours, in the first days of the disease, until it operated on the bowels, after 
which it was administered in smaller doses, or at more distant intervals. 
Here was the union of a non-laxative with laxative salts, constituting sub- 
stantially the practice afterwards advised by Dr. Stevens. At an earlier period 
still, 1817-19, Dr. Perlee has used with advantage, as a laxative, the bitartrate 
and the carbonate of potash, combined in such proportions as to give a slight 
excess to the latter. Dr. Hulse, although admitting a deficiency of the 
saline ingredients of the blood, does not seem to have founded on it any 
part of his practice. During the excitement, he gave from half a grain to 
a grain of camphor, with from three to five grains of nitrate of potash 
every two or three hours, and allowed effervescing draughts of tartaric acid 
and bicarbonate of soda. 

The committee of the Societe Medicate de la Nouvelle Orleans, in their 
account of the epidemic of 1839, inform us that a solution of muriate of 
ammonia was tried by some of them in the third stage of three cases, when 
many bad symptoms were present, and two of the patients recovered ; and 
Dr. Thomas informed them that he had obtained a similar result in one re- 
markably bad case. 

In the other printed accounts so often quoted, I do not find any notices 
of this practice worth transcribing; and my notes of unpublished experience 
are equally destitute of any observations on this class of remedies. 

It would appear from all that has been said, that the method proposed by 
Dr. Stevens has not found favor enough with our physicians to secure it a 
trial. Now, apart from the theory of reduction in the saline ingredients of 
the blood, and the propriety of restoring them, whether that loss preceded 
or followed the morbid excitement of the solids, there would seem to be two 
modes in which the non-purgative neutral alkaline salts might be service- 
able in yellow fever. First, they are refrigerant, and might, therefore, in 
liberal quantities, abate the heat and excitement of the second stage, and 
thus diminish the necessity for bloodletting. Second, they are diuretic, 
and might excite and maintain the function of the kidneys, which so often 
fails, undoubtedly to the injury of the whole organism, by subjecting it to 
the impress of the retained elements of the urine. 

In support of this recommendation, I shall cite but a single authority. 
In the epidemic of 1823, Dr. Cartwright found that after he had by diu- 
retics increased the secretion of urine, both the skin and liver began to re- 
sume their functions. 

Sulphate of Quinine. — Although in the definition of yellow fever pre- 
vol. ii. 22 



338 THE PRINCIPAL DISEASES OF THE 

fixed to this article, it is represented as a fever of one protracted paroxysm, 
that is, a short continued fever — which is undoubtedly true — nevertheless, 
in many seasons and localities, it has displayed a remittent type, always 
terminating in the third stage, however, by the fourth day, and not running 
on like the ordinary remittents of the country. This trait of character is 
the result, in all probability, of one of the two following causes. 1st. It 
may be that this disease is in fact the offspring of a modification of the same 
cause which produces our common autumnal fever. 2d. It may have a cause 
specifically distinct, and be modified in its type by the remote cause of the 
latter disease. Without going into an inquiry as to the relative claims of 
these two hypotheses, we may admit that whenever the fever presents a re- 
mitting character, the treatment adapted to that form of fever will, apriorij 
be found beneficial. This is the view under which the sulphate of quinine 
has been administered in certain epidemics — a practice which, within the 
last few years, has excited in New Orleans and Mobile a considerable degree 
of controversy. Claims of priority in its use going back to 1837 and 1835 
have been set up by different gentlemen ; and while some have condemned 
the practice altogether, others have looked to its first employment as a source 
of reputation. 

Without looking beyond the limits of our own Valley for old evidence of the 
employment of the bark in yellow fever, we may go back to 1825, when 
Dr. Cartwright, Dr. McPheters, and Dr. Monette, especially the two former 
administered the sulphate of quinine even when there was preternatural heat 
of the skin, and found it beneficial.* A few years afterwards, Dr. Dodd, 
whose publication was made in 1831, f made a far more liberal use of it, and 
obtained very satisfactory results. After an energetic resort to venesection 
and other means of reducing the excitement, till the pain began to abate 
and the pulse to soften, he administered the sulphate of quinine or the sul- 
phate of corninej in large doses, usually in conjunction with powdered cinna- 
mon and ginger. If remission took place in twelve or twenty-four hours under 
his antiphlogistic treatment, he gave from fifteen to twenty grains every hour 
until 80 or 100 grains had been taken, which he found sufficient, but if 
forty-eight or seventy-two hours were required to effect an adequate abatement 
of the febrile action "from twenty to thirty grains were given every twenty 
minutes or half an hour, until 100 or 150 grains had been taken, and then 
a less quantity at longer intervals." In illustration and support of this 
practice he published a considerable number of successful cases : and as 
the quantity administered has not since been surpassed, perhaps not equalled, 
Dr. Dodd may justly be regarded as the first to establish the safety of this 
practice. 

In 1832, Dr. Halphen,§ in New Orleans, when treating cases of yellow 

* Am. Med. Rec. vol. ix. f West. Jour. vol. v. p. hi. 

X [Cornine is an alkaloid resembling quinine, extracted from the bark of the Cornus Florida. — Ed.] 

§ Mem. Sur. Le Choi. Morb. Complique d'une Epid. Fiev. Jaune. 



INTERIOR VALLEY OF NORTH AMERICA. 339 

fever complicated with epidemic cholera, administered the sulphate in combi- 
nation with lactucariurn. 

His memoir contains the details of a great number of cases in which ac- 
cording to his judgment the curative effects of the prescription were so obvious 
that he regarded it as le remede par excellence. His standing prescription 
was: — 

R.— Sulph. Quin. 9ii. 

Lactucar. grs. vi. vel. viij. 

Misce. Fiant. pil. - - - - - - xii. 

He generally ordered one of these pills every fifteen, twenty, or thirty 
minutes, and frequently administered the same medicine per anum. 

In 1835, Dr. Stone, as he informed me, began the administration of the 
sulphate in the Charity Hospital on the final subsidence of the fever, but after- 
wards gave it in the first remission, while thirst and headache were still present. 
Under its use, these abate, and perspiration comes on. He gives from five 
to ten grains at once, repeating the dose till roaring in the ears is pro- 
duced. During its use he keeps the patient perfectly quiet on his back 
and gives him cold drink. As a preparation for its use he sometimes 
bleeds, and generally cups and purges moderately with calomel and castor 
oil. If called for the first time to a case which presents a remission, he pro- 
ceeds at once to the administration of the sulphate. He has seen black 
vomit occur after the administration of this medicine but the number of 
instances is very small, and it seemed to be brought on by the patients 
rising imprudently from bed. 

Dr. Mackie, as he informed me began the exhibition of the sulphate in 1837 
by injection only, giving it in 1839 by the mouth, and has continued 
it ever since, being in fact one of the firmest advocates of the practice 
in New Orleans. He depletes by the lancet and cups, opens the bowels 
with injections, and then gives at a single dose twenty or thirty grains 
of the medicine, which in general he finds sufficient. If the stomach 
be irritable he administers it by injection. He again cups if necessary 
to relieve local affections, and then administers the sulphate in smaller 
doses. In the Charity Hospital, 1839, Dr. Mackie and Dr. Hunt, who 
that year began the exhibition of the sulphate, made a number of ex- 
periments on its physiological action, with a view to its use in the fever. 
The results were reduction of the pulse below its normal frequency, once 
to forty-eight in a minute ; sleepiness ; perspiration ; roaring in the ears, and 
slightly dilated pupils, with all of which except the last the profession were 
familiar. When the medicine was administered in large doses it was found 
unaltered in the urine.* 

Dr. Harrison seems to have begun its exhibition this year, and the results 
were in general highly satisfactory ; he is a zealous advocate of the practice, 

* New Orleans Med. Journ. vol. ii. p. 331-2. 



340 THE PRINCIPAL DISEASES OF THE 

but like Dr. Stone, has lost two patients with black vomit, after their sys- 
tems had been brought completely under the influence of the medicine. 

In the same season, Dr. Jones entered on its use, after venesection and a 
mild cathartic, and saw from thirty to fifty grains at a dose produce the 
happiest results. His patients have, however, occasionally died with black 
vomit notwithstanding the fever seemed to be cut short by this treatment, 
and, as he found the recovery of his patients generally tedious, he has 
abandoned the practice. 

In 1837, Dr. Lambert, a Creole, was among those who made a decisive 
use of the sulphate, and exerted an influence on many other physicians of 
the city, in its favor.* In 1839, Dr. Buegnot began to employ it, and 
during that season, but still more, in the epidemic of 1841, he and Dr. 
Lewis, without concert, resorted to it immediately after very copious or 
syncopal bleedings, producing an artificial remission, with the effect, accord- 
ing to the former, of curing the fever as if by enchantment. In a report 
already quoted, to the French Medical Society, of New Orleans, on the for- 
mer epidemic, the committee present an elaborate criticism on this practice, 
and insist that its beneficial effects were limited to cases which partook 
largely of an intermittent character. They declared that death occurred 
after the system had been brought under the influence of the quinine, and 
show that the epidemics of 1837, '39, and '41, were per se less fatal than those 
of former years, and declare that in their own practice, under the use of 
moderate venesection, cupping, leeching, laxatives, enemas, refrigerating 
drinks, and topical bathing, but one out of fourteen died. Dr. Thomas in 
his report on the fever of 1841, took nearly the same ground. 

On the whole, it may be said, that the efficacy of the sulphate of quinine 
in the yellow fever of New Orleans is at this time a question on which its 
physicians are not agreed. 

According to Dr. Lewisf the sulphate of quinine has signally failed in 
every form of yellow fever, in Mobile. In my inquiries of its physicians 
I came to nearly the same conclusion, although from the extensive sources 
of malaria which surround it we might expect that its yellow fever, more 
than that of some other places, would require that medicine. And in the 
opinion of some of its physicians this is the case, for Dr. Gayle informed 
me that in 1843 he treated a considerable number of patients on that plan 
with great success. In his monograph, Dr. Hulse informs us that in the 
yellow fever of Pensacola Bay, he had used the sulphate too little to judge 
of its powers. In the fever of Galveston, 1839, Dr. Smith did not employ 
that medicine. In the Rodney fever of 1843, Drs. Andrews and Williams 
did not use it. In the Woodville epidemic of 1844, Dr. Kilpatrick found 
that it uniformly acted well, when preceded by venesection and cathartics, 
producing gentle perspiration, composing the system, and imparting tone to 
the stomach. Experience taught him, however, that when given alone it 

Dr. Buegnot, New Orleans Med. Jour. vol. i. f New Orleans Med. Jour. vol. i. p. 427. 



INTERIOR VALLEY OF NORTH AMERICA. 341 

produced or aggravated gastric irritability, and he at length fixed on the 
following compound : — 

R. — Sulphate of Quinine, - - - - Qij. 

Lupulin, ------- gss. 

01. Pip. Nig., fgj. 

Tinct.Opii, f^j. 

Gum Arabic, - - - - - - q. s. 

Fiant pil. xl. 

Of which he gave one every hour or every two hours. 

To return to unpublished experience. Dr. Harney at Baton Rouge, in 
1843, gave large doses of the sulphate in combination with calomel, to 
three patients in an advanced stage of the fever, and they all recovered ; 
but he had previously given it without effect in smaller doses. In the 
Natchez epidemic of 1837, Dr. Davis treated seventy cases without the 
lancet. After the operation of a cathartic, he resorted to the following 
combination : — 

R. — Sulphate of Quinine, - - - - grs. xx. 
Calomel, __---_ grs. x. 
M. fiant pil. viij. 

Two of these pills were given every two hours. He did little 
besides, and his patients recovered. In 1839 this plan did not succeed, 
but on the third day, after free depletion, it was attended with the best 
effects. At Vicksburg, in 1843, Dr. Hicks, after free bleeding and purg- 
ing to reduce the excitement, gave small doses of sulphate of quinine com- 
bined with sulphate of morphine with happy effect. In 1841 at the same 
place, Dr. Balfour found, that towards the close of the epidemic, the 
copious bleeding required in the early part of the season could not be borne, 
and he then dressed the blistered surfaces of his patients with sulphate of 
quinine and sulphate of morphine, administered the former by injection, 
and at length by the mouth with satisfactory results. 

Such is the history of the employment of the sulphate of quinine, in 
the yellow fever of our Valley. Let us now devote a moment to the con- 
clusions which it suggests, and the fitness of the medicine to the treatment 
of that fever. 

It is undeniable that the quinine has proved beneficial in the practice of 
a number of our physicians ) but can it be regarded as a specific, even in 
the modified sense in which it is a specific in autumnal intermittent fever ? 
I think not; for in the hands of several physicians, it has not produced any 
decided benefit, and all who have used it extensively, have seen patients die 
with black vomit after their systems had been thoroughly brought under its 
influence. Indeed, of its value in yellow fever, unmodified by any autum- 
nal intermixture, we have not any satisfactory proof. Nevertheless, so many 
epidemics present a mixed character, that even limited to them, its impor- 
tance is very considerable. When no alliance of this kind exists, I am 



342 THE PRINCIPAL DISEASES OF THE 

disposed to believe that it may shorten the stage of excitement, if exhibited 
in large doses immediately after copious depletion. Its narcotico-sedative 
effects on the nervous system of animal life, and the centrifugal determina- 
tion of the blood which it favors, as is shown by the diaphoresis which 
follows its exhibition, are well fitted to extinguish the morbid excitement. 
But, in pure yellow fever, is this the subdual of the disease ? It would seem 
not; for after the patient has lain for two or three days under its influence, 
in what Dr. Lewis calls the " state of calm," collapse, black vomit, and 
death may happen. There is, then, an insidious lesion of the system, which 
it does not reach : a root of malignity which it cannot eradicate. In the 
treatment of the most dangerous intermittents — either inflammatory or con- 
gestive — it does not display this impotence ; for after its impress on the 
system is established, no ulterior fatal symptoms need be apprehended. 
The third stage of yellow fever is not, in fact, the same pathological condi- 
tion with the apyrexia of an intermittent. It ends in health, or collapse 
and death ; while the apyrexia of the intermittent never terminates in 
health or death, but in a new paroxysm. We should not then be surprised 
at a difference of effect in the sulphate of quinine in the two cases; nor at 
the small degree of success which has as yet followed the efforts to ward off 
the collapse of yellow fever by treating its third stage with the quinine. 
We must now pass on to other remedies. 

Applications to the Skin. — These may be divided into three classes, 
— hot, cold, and irritating. I shall here consider their use in the first and 
second stages of the disease. 

1. Hot bathing, especially of the extremities, has been found beneficial 
in the first stage, as a means of producing reaction. In the second, tepid 
bathing and sponging, have often reduced the heat and exercised a soothing 
influence on the nervous system, thus relieving local pains and at the same 
time preparing the skin for a resumption of its functions. 

2. Cold water as a dash has been used to excite 5 reaction, but the reports 
are not greatly in its favor. Subsequently, in the stage of excitement and 
heat, it has by some of our physicians been extensively applied, but on the 
whole, seems to have failed to afford the relief that was anticipated, and 
some of them thought it did harm by reducing the temperature of the sur- 
face too much, and increasing the internal congestions. The restricted or 
topical application of cold water, either with or without some vegetable 
acid, as vinegar or lemon-juice, has proved beneficial in relieving the head 
and spinal region from pain and congestion. Cool and fresh air, not 
directed upon the naked surface, have been found beneficial. 

3. Irritants. — The hot baths applied to different parts of the body, as 
the lower extremities, epigastrium, and spine, in the cold stage should be 
rendered stimulating with mustard, capsicum, salt, turpentine, or ardent 
spirit. In the second stage, a sinapism or blister on the epigastrium, has 
often relieved the stomach from irritation, and reconciled it to the impress 



INTERIOR VALLEY OF NORTH AMERICA. 343 

of medicines. The same applications to the nucha and loins have mode- 
rated the head and back-ache; but on the whole, dry cupping and local 
tepid bathing, seem to have done more good than severe counter-irritation. 

Sudorifics. — I have been told of a man who on being seized with yellow 
fever, drank a pint of whiskey and retained it on his stomach. He fell 
asleep, a drenching perspiration came on, and continuing for a whole night, 
terminated the disease. The case might, perhaps, not have been yellow 
fever, but it seems exceedingly probable that if in the early periods of the 
disease such a perspiration could be excited it might prove curative. The 
stomach, however, is in almost every instance too irritable to sustain either 
sudorifics, generally nauseating, or diluent drinks in sufficient quantities, 
and hence, until the fever by other means has been so far reduced, as that 
spontaneous diaphoresis has come on, sudorifics seem to have done but little 
good. Of the propriety of maintaining and even promoting the secretion 
of the skin after it has thus spontaneously begun there can be no doubt, as 
the centrifugal direction which it gives the blood, is well-calculated to com- 
plete the removal of the internal congestions. It is perhaps by its sudo- 
rific influence, as much as any other that the sulphate of quinine has done 
good after sanguineous depletion. In promoting this function, great care is 
necessary not to irritate the stomach ; and also not to carry the effect too 
far, as several physicians have found excessive sweating injurious. Of the 
diaphoretics that have been used, the best, perhaps, are the Spiritus Minde- 
reri • the common saline mixture ; laudanum and the spirit of nitrous ether, 
to which, when the stomach will bear it a little wine of ipecac, may be 
added; small doses of Dover's powder; and an infusion of sage, serpentaria, 
or orange leaves, the last of which is a favorite ptisan. 

Concerning the Spiritus Mindereri in connection with another medicine, 
I may record the following facts communicated to me by Dr. Nott of 
Mobile. In the epidemic of 1843, he treated his first twelve cases by active 
bleeding and purging; and lost every one. He then resolved to give crea- 
sote in the Spiritus Mindereri, in the proportion of twenty drops of the 
former to eight ounces of the latter. A tablespoonful every two hours was 
the dose, and the stage of excitement the period for its administration. It 
calmed the irritability of the stomach, and for a month after he adopted 
this practice he did not lose a single patient. The fever of that year was 
not however of a very mortal character. 



SECTION III. 

REMEDIES IN THE THIRD STAGE. 

Everybody knows that in our ordinary autumnal remittent fever, the 
patient either dies or shows signs of recovery as soon as the febrile com- 
motion ceases. It is very different, however, in yellow fever. Whether 



344 THE PRINCIPAL DISEASES OF THE 

combated by active treatment; or left to itself, the febrile excitement ceases 
in two or three days, not to be renewed ; but the patient cannot be said, on 
that account, to begin to convalesce, for the hour of danger has not yet 
arrived, and may not come for even a longer period than has elapsed from 
the beginning of the disease. In this stage, it is true, the patient often 
desires, and is able to rise and dress himself; but all experience proves that 
such liberties are likely to be fatal, and that, should he even remain quietly 
and comfortably in bed, and avoid every irregularity, a revival of gastric 
irritability, a failure in the powers of the heart, and the fatally ominous 
black vomit may supervene, when every appearance had for twenty-four or 
forty-eight hours been auspicious. 

It is in this stage much more than in the preceding one, that we find the 
peculiarities of yellow fever. In fact, it is not identical with any other 
known pathological state; though, as we shall hereafter see, it bears some 
resemblance to the collapse of epidemic cholera. 

Now the question before us is, what can be done to conduct the patient 
safely through this treacherous calm ? But another inquiry should be first 
proposed, which is, whether art can do anything to assist nature, and whether 
those who live and those who die would not experience the same fate if let 
alone ? It is quite certain that many who have been violently ill in the 
preceding stages, have passed successfully through this ; while others, who 
were reputed to have mild attacks, have ultimately died. It is equally cer- 
tain, that under different modes of treatment in this stage, both recoveries 
and deaths have taken place ; facts which favor the idea that art can 
achieve but little by her medications. But, waiving for the present a de- 
cision on this point, we may affirm that she is able to point out what con- 
tributes to a fatal termination, and thus to preserve life by obviating external 
causes that would destroy it j and this brings us to the regimen which all 
our physicians have found necessary, and for which it is needless, therefore, 
to cite individual authorities. 

1. The patient must be kept in bed, and not allowed even to rise to the 
close stool, or at least to sit long upon it. He should be well, but not op- 
pressively, covered with bed-clothes. 

2. Whatever may be his appetite, he should not be allowed to irritate or 
load his stomach with food. 

3. All debilitating or irritating medications should be carefully avoided, 
especially purging and copious sweating. 

4. Care should be taken that urine does not accumulate in the bladder. 

5. Every kind of mental irritation and depression should, as far as pos- 
sible, be obviated. 

A violation of any one of these precepts may suddenly develop fatal 
symptoms, even when the condition of the patient is in all respects auspi- 
cious. 

We come now to inquire what positive treatment this stage of the disease 



INTERIOR VALLEY OF NORTH AMERICA. 345 

may in different cases demand ; in doing which, it will be necessary to 
recognize the pathological conditions which make it up, the whole of which 
may never exist in the same patient. We have, then, 

1. A reduction of the vital forces of the solids. 

2. An impoverished condition of the blood, with hemorrhages. 

3. Congestions or unsubdued inflammations in some of the tissues. 

4. A suspended or reduced state of the great secretions, renal, hepatic, 
and cutaneous. 

5. Diarrhoea. 

6. That morbid condition of the stomach on which the production of 
black vomit depends. 

All the measures which do good in this stage of the disease operate to 
the correction of one or more of these pathological details. 

Before proceeding to enumerate them, it is proper to say, that in favora- 
ble cases, upon the subsidence of the stage of excitement, but few of these 
conditions exist. The exhaustion is not great, the circulation becomes 
equable, the appetite returns, and the secretions revive. Such cases as 
already intimated, require no positive treatment. It is only necessary to 
insist upon attention to the rules mentioned above, and in a few days he 
may be allowed to dress himself, and re-engage in his duties. But these 
cases are not very numerous, and we come now to consider what art may be 
required to perform. 

1. As to the exhaustion of the vital forces, it is sometimes extreme. Its 
greatest manifestations will in general, be in cases in which the morbid ex- 
citement is intense ; or in which, from an original character of malignity, 
the period of excitement was replaced by an adynamic and ataxic condition. 
All such cases demand tonics and stimulants. From analogy, it might be 
supposed that the bark and the sulphate of quinine were well adapted to 
this emergency, but such is not the fact. The stomach is in general too 
irritable to tolerate a liberal use of the former, and the latter is too sedative 
in its action ; nevertheless, when the stomach will receive the cinchona in 
substance, decoction, or tincture, it may be administered in moderate quan- 
tities, and the sulphate may be given in grain or two-grain doses, combined 
with stimulants. The practice, however, which on the whole, our physicians 
have found most eflicient is alcoholic stimulation. Without presenting 
a tiresome list of authorities on this point, I may say that some prefer 
French brandy as most acceptable to the stomach, and administer it in 
large quantities ; others have found ale or porter most useful : others cham- 
pagne, wine-whey, and egg-nog. In all cases, if delirium, or gastric irri- 
tability or frequency of the pulse should come on, they must be discontinued. 
But agents more strictly pharmaceutic may be used. An infusion of aris- 
tolochia serpentaria is often beneficial, acting at once as a tonic and sudorific. 
It constitutes a good vehicle for the Spir. Mindereri, which is adapted to this 
stage, as well as to that which precedes it. Carbonate of ammonia, camphor, 



346 THE PRINCIPAL DISEASES OF THE 

musk, and opium, or the sulphate of morphia, are also proper and more 
especially demanded when there is great restlessness, or spasmodic action 
in the form of hiccough or subsultus tendinum ; when delirium arises during 
this stage, and has not subsisted from the stage of excitement, those medi- 
cines are not contraindicated by, but may abate it. 

As the greatest of all restoratives is food, the question presents itself, 
how far the indication we are now considering can be fulfilled by adding it 
to the therapeutic resources which have been mentioned. To be a restora- 
tive, two gastric conditions are necessary : — 1. The stomach must retain it 
without inconvenience ; and 2d. Must be able to digest it. Now that organ 
appears in a great number of cases not to present these conditions ; and the 
most reliable experience prohibits its use, except to the most limited extent, 
until the stage of exhaustion (in which it might seem indicated) has passed 
by, and the healthy appetite, feelings, and excretions of the patient indicate 
that convalescence has really commenced. Even after such manifestations, 
a hearty meal has produced black vomit and death. When food is given 
in the stage of exhaustion, it should be semi-fluid, and gelatinous, or amy- 
laceous. 

2. Surviving Inflammations. — I have said that stimulants, tonics, and 
nutrients, sometimes increase the gastric irritability or otherwise make the 
patient worse, and must be laid aside. To what can this be owing ? We 
can scarcely doubt that it results from unextinguished gastritis ; but how 
can this be, as in the stage of the disease we are now considering, the febrile 
excitement has ceased? The answer is, that not the inflammation of the 
stomach only, but that of the bowels, kidneys, brain, and other organs, is not 
primary, occasioning the fever, which would therefore continue till it ceased ; 
but secondary or simultaneous with the fever, and cannot cease with it; for 
the reason that time is necessary to the resolution of every inflammation. 
Hence when the constitutional affection has run its prescribed or self-limited 
course, a certain amount of gastritis, duodenitis, nephritis or cerebritis, may 
remain (not ingravescent, but declining), and for a time render stimulants 
injurious. In whatever organ the inflammation may be seated, that organ 
will of course be unable to resume its specific function ; and the more total 
that inability, the greater the danger. Thus if delirium, existing in the 
hot stage, should survive its decline, or the vomiting continue, or the 
secretion of urine or bile continue to be totally suppressed, or diarrhoea 
follow on the purging in the stage of excitement, the prognosis would be bad, 
and a post-mortem inspection would show inflammatory congestions and 
disorganizations in the organs affected. Of these surviving and subacute 
inflammations, those of the stomach, brain, and kidneys, are the most 
momentous ; and of these again, that of the stomach, or of the stomach and 
duodenum, so frequently combined, is not only most frequent but most 
embarrassing, because of the obstacle which it presents to the administra- 
tion of medicines or food. Now what can be done to promote the resolu- 



INTERIOR VALLEY OF NORTH AMERICA. 347 

tion of these inflammations ? The first and greatest remedy is time. From 
the hour when the fever subsides, they begin to diminish, and if we wait 
patiently, nature may effect their final resolution. But this, perhaps, is 
not always proper, and never agreeable to the feelings or sense of duty of 
physicians, who like ours, are always disposed to energetic effort. That 
effort in these cases, however, must be made with prudence and moderation. 
Venesection and purging, the great antiphlogistics, are of course out of 
the question • but in many cases local bleeding, or dry cupping may be 
practised with advantage j and in all cases counter irritation will be proper. 
The local application of cold, especially when the head is affected, may be 
permitted ; but the perpetual laving of the skin over the suffering organ, with 
tepid water is preferable. When the kidneys are affected, the oil of tur- 
pentine in connection with more specific diuretics may do good. The liver 
being inflamed, the internal and external use of nitro-muriatic acid should 
not be neglected. Lastly, when the stomach is the chief seat of the phlo- 
gosis, pellets of ice are among the internal remedies most to be relied on. 

In many cases the inflammation during the fever may have been so 
intense as to decompose the tissues, and greatly abridge the duration of 
the stage we are now considering. In others there may have been only 
passive congestion, which may be roused into inflammation by excessive 
stimulation on the decline of the hot stage. 

The diagnosis of these smothered and expiring inflammations is of course 
attended with difficulty; for an irritable stomach, delirium, suspended secre- 
tion of bile and urine, and a diarrhoea, may all exist from nervous irrita- 
bility or torpor. Of course the sagacity of the physician must be severely 
tried by such cases. 

3. Impoverished and Deteriorated State of the Blood. — It cannot be 
doubted, that the loss of a part of the fibrine and the salts of the blood (not 
to refer to hypothetical lesions of that fluid, which we have not the means of 
verifying), must constitute one of the sources of danger in the third stage of 
the fever, as we have already seen the hemorrhages of that and the preceding 
stage, seem to have this condition of the blood for their proximate cause. 
That it interferes with the revival of the vital forces of the solids and the 
restoration of the secretions may be fairly assumed. It is desirable then to 
correct it; but can this be done by any direct effort of art ? Will the ad- 
ministration of food containing fibrine, and of the salts which belong to the 
serum, really increase those ingredients of the blood? In regard to the 
former, the answer must be in the negative, unless the digestive organs were 
capable of forming chyle, which presupposes the absence of that condition 
of the blood which it is proposed to correct. In regard to the latter, it is 
possible that the absorption of saline solutions from the stomach, if that 
function can be performed, may contribute to the saline impregnation of the 
serum. But still as the system has its peculiar method of incorporating the 
materials of the blood, it is conceivable that this mode of supplying them 



848 THE PRINCIPAL DISEASES OF THE 

may fail. Whence then can the vital fluid be replenished with its lost 
elements ? The answer must be from the solids, which being but the elements 
of the blood in a different mode of existence, afford to the absorbents the 
means of recuperation. Of the activity of this interstitial absorption, in 
the decline of, and during the early convalescence from fever, we have evidence 
in the rapid emaciation which then takes place ; and on it we must perhaps 
rely for the restoration of the blood to a normal condition after an attack 
of yellow fever. Thus preyed upon, the solids, as soon as their vital proper- 
ties have begun to improve, and they are stimulated by a healthier blood, 
begin to demand retribution, and hence the insatiable appetite of convales- 
cence, — an appetite, as some one has well observed, that is not limited to 
the stomach, but seems to reside in every fibre of the body, and has for its 
final cause the necessity of repair felt by the system. 

But if it is uncertain whether art can contribute directly to an amelioration 
of the blood in the third stage of yellow fever, it is possible, perhaps, for her 
to correct the effects of its deterioration. These we have already attempted 
to show, are chiefly the hemorrhages so characteristic of this fever. When 
they begin during the acme or decline of the stage of excitement, they 
partake largely of the character of active hemorrhages, that is, there is local 
congestion and vis-a-tergo, in connection with diminution of fibrine. Such 
hemorrhages are not to be dreaded, for the system is not then in a state of 
exhaustion. They are even sometimes salutary as carrying off local hyper- 
emias. But when they continue long after the arrival of the third stage, or 
appear then for the first time, and especially if the patient has been freely 
bled, or he shows signs of a very languid circulation, they should, if profuse, 
excite deep concern, and if possible be checked. This is to be attempted 
by the exhibition of solid opium ; by tannin dissolved in iced-claret, in the 
proportion of 3ss. to 3viij. ; by an iced lemonade of elixir vitriol; by as- 
tringent gargarysms when the flow is from the mouth, and by the application of 
lunar caustic, when it takes place, as often happens, from leech-bites. These 
are the means on which the physicians of New Orleans and Mobile place 
most reliance. The acetate of lead has no doubt been used, but I have no 
information concerning it. 

4. The Suspended State of the Secretions. — What might be said under this 
head has been in a great degree anticipated. In addition to the 01. Tereb., 
already mentioned, the spirit of nitrous ether is valuable. As a means of 
reviving the action of the kidneys, perhaps a strong infusion of green tea 
(thea viridis), deserves a trial. Generally acceptable to the stomach, 
astringent and therefore antihemorrhagic, stimulating, containing a pecu- 
liar principle (theine) analogous to the fibrine of the blood, and acting on 
many persons as a diuretic, it would seem well calculated to be useful in 
the pathological state we are now considering. To assist the nitro-muriatic 
solution already recommended for the restoration of the functions of the liver, 
the cold infusion of wild cherry-tree bark (jprunus virginiana), prepared 



INTERIOR VALLEY OE NORTH AMERICA. 349 

by displacement, suggests itself. But let us pass to the skin. All who 
have treated yellow fever, have perceived the great importance of restoring 
and maintaining its functions from the moment when the heat and dryness 
of the stage of excitement begin to abate until convalescence is far ad- 
vanced. In some cases the perspiration is in excess and requires to be re- 
strained by dry and harsh frictions with salted towels, or by hard spongings 
with diluted lemon-juice, vinegar, or the mineral acids. In this languid 
state of the cutaneous circulation, often accompanied with petechias and 
more or less of a purple hue with diminished temperature, in addition to 
the applications just mentioned, strong infusions, or tincture of capsicum, 
applied hot, by friction, and the immersion of the feet in a similar bath, 
are of great moment. In other cases the skin may be cool or of a natural 
temperature, and dry, when a simple pediluvium, an increased quantity of 
bed covering, and the internal use of moderately-stimulating diaphoretics, 
mentioned under our first head, are to be employed. In short the main- 
tenance of the circulation, temperature, and moisture of the skin, in proper 
degrees, is of the utmost importance ; as it not only diminishes visceral 
congestions, but its reactive influence on the liver is decisive. But this 
condition cannot be met unless the patient be strictly confined to bed, and 
the surface of his body, adequately, but not oppressively, covered. 

5. Diarrhoea. — A bilious diarrhoea need not excite apprehension or 
prompt to active measures, as a restoration of the secretion of bile is 
generally followed by recovery. But when the discharges are watery, 
offensive, or dark and sanguineous, its continuance is to be deprecated. 
Among the means of preventing or checking this discharge, the solution of 
tannin holds deservedly a high place. Other astringents, as the tincture of 
nut-galls in a cold infusion of cherry bark, will do good ; lime-water and 
milk are proper, solid opium should not be neglected, and amylaceous 
injections, with vegetable astringents and laudanum, are not to be overlooked. 
Throughout its continuance, as indeed during the whole of that stadium of 
the disease to which it belongs, and whether it occur or not, the patient 
should use a bed-pan, and on no account rise to the close stool. 

6. Black Vomit. — While several if not all the pathological conditions we 
have considered are the causes of others, black vomit cannot be regarded 
as the cause of any other, or of the mortal termination of which it is but 
the precursor. A patient dies with or after black vomit, but not from it. 
We cannot regard it in any other light than the expression of a pathological 
state that is, in general, fatal. To prevent black vomit is to accomplish the 
objects which have been reviewed, to cure black vomit is to cure the morbid 
condition on which it depends, which we had not been able to prevent, and 
which is but the confirmation or full development of the third stage of the 
fever. It is one of the great peculiarities of this fever, that it always before 
death is signalized by the production of this revolting material. It is not, 
to be sure, always thrown up in fatal cases, but as far as post-mortem 



350 THE PRINCIPAL DISEASES OF THE 

researches have extended, it has in such instances been found either in the 
stomach or bowels. In some instances the patient expires in an hour or less 
after the first ejection of this fluid, in a few he has lived two or three days. 
The number of recoveries (as we have already stated) after the appearance 
of this symptom, varies in different epidemics, but on the whole seems to 
be increasing; either from a change in the character of the fever, or from 
improved methods of treating its final period. 

As already stated black vomit is ejected "without nausea by a sudden 
and spasmodic eructation ; an action of the diaphragm not very different 
from that which constitutes the hiccough so often its associate. It is also 
occasionally discharged from the bowels and kidneys, and Dr. Levert has 
seen it exuding from the inside of the cheeks. Although in most cases 
the vital forces of the circulation are greatly reduced when this symptom 
comes on, instances are not wanting of its supervening when the patient, 
improperly, was dressed and walking about. Other anomalies attend 
occasionally on this state, indicating a kind of revived excitement in the 
brain and nervous system of animal life. Thus the patient may be rather 
deliriously imaginative and playful, so as to amuse himself with this 
ejection ; or delivered over to venereal desires and orgasms only a few minutes 
before he expires. It would seem almost futile to speak of the treatment 
of this stage of the disease, which with every physician is, in fact, but a 
part more or less modified of the treatment already detailed. Some cases 
not subjected to any treatment have recovered, suggesting the idea that 
others, said to have been cured, would in reality, if left to nature, have ter- 
minated in the same manner. Nevertheless, I shall enumerate some of 
the measures which have been thought to do either good or harm in this 
state. 

Dr. Ticknor saw the hiccough attendant on this stage removed by opium 
and the bicarbonate of soda with a plaster of pitch, opium, and camphor, 
between the shoulders. He stopped one case of black vomit and saved his 
patient by charcoal alone. To another he gave eighty grains of calomel 
and afterwards charcoal with. oil of turpentine, and administered injections 
of mucilage, lime-water, and balsam copaiva. Recovery followed. Dr. 
Hulse has seen the turpentine arrest the black vomit, but still his patients 
did not recover after that symptom was fully developed. 

Dr. Fearn, Dr. Ross, and other physicians of Mobile treat this stage with 
tannin dissolved in claret. Dr. Lopez of the same city has found stimulants 
injurious, and relies on ice by the mouth, and ice-water injections. Dr. 
Meux, of New Orleans, relies on ice and London porter. Dr. Jones of the 
same city gives ice and ale. In 1841, Drs. Mackie and Campbell had eight 
recoveries, in their Circus Street Infirmary, after black vomit appeared. 
The patients were treated with a stimulating liniment, epigastric bleeding, 
and porter internally. Dr. Stone has seen black vomit stopped by mag- 
nesia, also by sulphate of quinine with alkaline carbonates, but prefers to 



INTERIOR VALLEY OF NORTH AMERICA. 351 

everything else the sulphate of morphine with those carbonates, in connec- 
tion with ale or porter, at the same time giving injections of broth with sul- 
phate of quinine. 

Many physicians do nothing in this stage of the fever, believing it better 
to leave the cases to nature than to irritate the stomach with medicines. 

With these citations I close the treatment of yellow fever. 



CHAPTER XI. 

MISCELLANEOUS OBSERVATIONS. 



SECTION I. 

MORTALITY. 

No fact in the history of yellow fever is better ascertained than that the 
relative mortality in different seasons is not the same, in which respect it 
but conforms to the law of all epidemic diseases. In some years it strongly 
tends to death under every mode of treatment, in others to recovery under 
methods equally diversified. These are inherent tendencies dependent on 
undiscovered causes, and while they baffle, may be said to justify the pro- 
fession. Even a discovery of these occult influences would not, in all pro- 
bability, change the results of practice. I have already intimated that 
some of our physicians believe that the disease has been progressively as- 
suming a milder character. If so it may at last cease to be the terrible 
scourge which it has hitherto been ; or making a circle it may again recover 
its lost malignity. But may it not be, that a diminished mortality in 
latter times is the effect of improved modes of practice ? That the practice 
has been to a certain extent altered if not improved, is quite certain, and 
the changes are in part negative, in part positive. Of the former the 
most important is the abatement in the mercurial, emetic, and purgative 
practice. Immense doses of calomel are no longer administered; the por- 
tion is now reckoned by grains, instead of scruples or drachms, and in the 
practice of many physicians, this medicine has been entirely replaced by the 
blue-pill. Emetics, notwithstanding the apparently well-founded encomiums 
of Dr. Cartwright twenty years ago, and the deservedly high authority of that 
gentleman in the South, are in latter years but seldom administered ; while 
drastic cathartics, and above all their daily repetition, are no longer thought 
of. The changes of a positive kind which have been introduced consist 
chiefly in a more frequent resort to local bleeding ; in greater reliance on 
injections, as a means of opening the bowels ; and on the introduction into 
practice of the sulphate of quinine, as a substitute for the bark employed 



352 THE PRINCIPAL DISEASES OP THE 

by some physicians, and as a remedy in cases where no physician would 
venture to administer the cinchona. That these modifications of treatment are 
real improvements, and have contributed to diminish the rate of mortality, I 
am compelled to believe although it is not possible from any existing 
statistics to demonstrate the fact. Perhaps I ought to generalize these 
remarks so far as to recognize in the greater reserve of the physicians of 
the present day a source of diminished mortality. The fever is no longer 
regarded as under the control of medicine, less therefore is done, the expec- 
tant method. is oftener pursued, and injuries which might result from 
excessive medication of any kind are thus averted. 

In proof that the diminished ratio of mortality may be justly attributed 
to the causes which I am attempting to assign, we have the following sta- 
tistics of the Charity Hospital of New Orleans. In the years 1825, '27 '30, 
and '33, the admittances were 1783 and deaths 931, giving a mortality of 
52-21 percent.; in 1839, '41/42, and '43, the number admitted was 3662, 
of deaths 1747, equal to 47*70, affording a diminution of 4-21 in the ratio 
of mortality in the average period of thirteen years. Now it was through 
this period that the change from a violent to a milder treatment took place. 

In attempting to assign the rates of mortality in this fever, difficulties 
almost insuperable are encountered. The greater number of cases in every 
epidemic, when we exclude the army and navy, are treated in private prac- 
tice, and a large majority of our physicians keep no records of their cases. 
There is, moreover, much uncertainty in the diagnosis of cases which do 
not prove fatal ; inasmuch as the disease prevails in the same localities, at 
the same time, and with symptoms which, in cases not running on to passive 
hemorrhage and black vomit, do not always distinguish it in a satisfactory 
manner, from our autumnal remittent fever. 

In the epidemic of 1833, Dr. Barton lost one out of 12*5; and Dr. Har- 
ris, one out of 20. In that of 1839, according to the Committee of the 
(French) Medical Society of New Orleans, of 490 cases, 34 died; making 
one out of 14. 

I have already stated that the Committee of the Creole Medical Society 
of New Orleans declare that the deaths in their practice, in the epidemic of 
1839, were as one in fourteen. Dr. Campbell informed me that in 1843, 
he lost one in eight ; Dr. Stone, that in the same year he had in his private 
practice, fifty cases before he lost a patient; he then lost four in a few days. 
How many he had in all, I did not learn. According to Dr. Lewis, in the 
epidemic of 1843, at Mobile, the number of cases treated was 850, of which 
240 proved fatal, or about one in 3-54. At Pensacola, in 1839, in private 
practice, Dr. Hulse treated 146, with the loss of only six, or one in 26-3. 

In the navy, Dr. Barrington reports on board the Hornet, 55 cases and 
8 deaths, one death in nearly seven ; on the Grampus, 36 cases and 4 deaths, 
one in nine ; on the Peacock, 38 cases, 9 deaths, one out of 4-22. The 
patients of the last of these ships, were sent to the Naval Hospital below Pen- 



INTERIOR VALLEY OF NORTH AMERICA. 353 

sacola. At the same hospital, as Dr. Hulse informs us, 18 cases were received 
from two French vessels, La Sabine and Le Dunois, of whom two died, or 
one in nine; but on board, immediately before, 5 out of 14 had died, or one 
in 2-8. 

In 1841, 156 were admitted into the same hospital, of which, according 
to Dr. Hulse, 13 died, making 1 in 12. In the same epidemic, the admis- 
sion into the Maison de Sante of Drs. Stone, Kennedy, and Carpenter, New 
Orleans, were 272, of which 63 died, making one in 4*15. 

In the Charity Hospital, in sixteen years, the only ones in which the 
deaths were accurately registered between 1818 and 1843, the number of 
patients admitted was 7,263; of whom 3,635 died, or one out of two. 
Thus we find the mortality of yellow fever ranging from this high ratio of 
one-half, or fifty per cent., to one in 26-3, or 3-8 per cent. 

If we bring together all the available data in this statement, we have pa- 
tients, 9,349, deaths, 4,023, giving as a general average one death for 2-323 
cases, equal to 43-04 per eent. If we detach from these amounts the patients 
of the Charity Hospital, we have 2,084 patients and 388 deaths, which 
gives one in 5-32, or 18-8 per cent. The mortality then in private practice 
is to that in the Charity Hospital as 18-8 per cent, to 50 per cent. In 
other words it is less than two-fifths. 

The differences in the ratio of mortality in private practice, may be in 
some cases owing to differences in practice, in others of diagnosis, [in some, 
of previous habits, Ed.] and in others of years. The high ratio of deaths 
in the Charity Hospital, compared with private practice, and that in the 
ships, the Naval Hospital at Pensacola, and even the private hospital in New 
Orleans, must be ascribed to the character and condition (when brought in) 
of its patients, seeing that it is an exceedingly well-ordered establishment, 
and is attended by the same physicians that practise in the city. Those 
who are seized on board the ships, and those admitted into the Naval Hos- 
pital, being under discipline, received early attention, and many of those 
who seek the Maison de Sante, are strangers in comfortable circumstances; 
but of the poor and isolated who are taken to the Charity Hospital, a large 
proportion are far advanced in the disease when carried thither; are often 
sent there, indeed, that they may be buried at the public expense. Not a 
few of them, moreover, are dissipated persons, who, although not more liable 
to the disease, perhaps, than others, are well known to be more liable to die 
from it. 



SECTION II. 

COMPARISON OF YELLOW EEVER WITH AUTUMNAL FEVER. 

In various places through the preceding chapters on yellow fever refe- 
rences have been made to autumnal fever, but, I now propose to institute a 
vol. ii. 23 



354 



THE PRINCIPAL DISEASES OF THE 



comparison between them. Materials for this are furnished in the histories 
which have been given ; and it only remains to bring them together. This, 
to a limited extent, has been done by Dr. Hulse in his monograph; and 
with more copiousness, but less concentration, by Dr. Lewis in his valuable 
memoir on the yellow fever of Mobile, both writers coming to the conclu- 
sion that they are distinct diseases. In my intercourse with the physicians of 
the South, I have ascertained that nearly all of them concur in that opinion. 
Many have, indeed, favored me with oral comparisons of the two fevers, among 
whom, I should designate Dr. Meux and Dr. Hester of New Orleans, and 
Dr. Hicks of Vicksburg, whose conclusions are entitled to the greater con- 
fidence, from the fact, that they are perfectly familiar with the endemic 
fevers of Alabama and Mississippi, as well as the yellow fever of the cities 
in which they reside. 

TABULAR VIEW. 



AUTUMNAL FEVER. 



YELLOW FEVER. 



GEOGRAPHY AND CHRONOLOGY. 



1. 



1. 



Prevails from the tropic to the latitude 
of 44°, and is often epidemic and mortal 
as far north as 43°. 
2. 

Occurs much more frequently in the 
country than the towns ; and is as pre- 
valent and violent in towns remote from, 
as those on the banks of the Mississippi 
River. 

3. 

Occurs sporadically every year, and 
rises annnally into an epidemic, in some 
part of the region in which it prevails. 
4. 

Scarcely ever appears in ships naviga- 
ting the Gulf of Mexico, especially in its 
intermittent type, while they continue at 



Prevails from the tropic to the latitude 
of 35° or a little higher ; but has occurred 
only once above the latitude of 32°. 
2. 

Almost limited to the cities and towns, 
and far more frequent in those on the 
banks, than those remote from the Mis- 
sissippi. 

3. 

Generally appears as an epidemic, but 
is sometimes sporadic. 

4. 
Often breaks out on board of ships, 
while out in the Gulf. 



5. 

Very commonly begins in June, never 
deferred beyond July, in which month it 
often becomes epidemic ; prevails greatly 
in August, sometimes even diminishing 
in September, at others keeping up and 
prevailing through October and Novem- 
ber. Reigns from three to four months. 



5. 
Rarely commencing in June, and 
scarcely ever more than sporadic in 
July ; often deferred till August even in 
New Orleans, and till the 10th or 15th 
of September in the smaller towns, fur- 
ther north. Most prevalent in that 
month and October. Reigns from two 
to three months. 



6. 6. 

Relapses well characterized or obscure After convalescence is completed, re- 
and insidious throughout the winter, lapses, now and then, before the setting 



INTERIOR VALLEY OF NORTH AMERICA. 



355 



multiplied, sometimes to an epidemic 
degree in spring, under the name of Ver- 
nal Intermittents. 



in of winter; none afterwards, open or 
occult, and no return the following spring. 



SUBJECTS. 



7. 



Affects native children and youth, not 
less than the immigrant; bestows no im- 
munity from subsequent attacks, but 
rather seems in many cases to invite or 
predispose to them ; continues therefore 
to return annually in insalubrious locali- 
ties, till it has permanently destroyed 
the constitutions of those assailed. Does 
not attack all strangers from higher lati- 
tudes. Does not give an exemption from 
yellow fever. 



Affects children born in the towns 
where it prevails, so slightly, as in most 
cases to pass unobserved, or does not 
affect them at all ; but, when they grow 
up, they are found to be exempt. One 
attack, especially during a violent epi- 
demic, bestows an immunity from future 
attacks, unless the individual should re- 
side for several years in a colder climate. 
Scarcely suffers any strangers to escape. 
Does not exempt from autumnal fever. 



SYMPTOMS. 



8. 



Attack generally gradual ; first parox- 
ysm mild, with an ingravescent cha- 
racter. Essentially paroxysmal, and 
presenting either a remission or an in- 
termission. Often of a tertian type, 
sometimes a double tertian, rarely a dou- 
ble quotidian. May prove fatal in three 
or five days, but shows no tendency to 
cease, even within a much longer period. 



In most cases sets in without premoni- 
tory ailments of any kind. Often violent 
on the first day. Does not necessarily 
manifest a paroxysmal, and never a true 
intermittent type. Fever generally ceas- 
ing, not to return, in forty-eight or 
seventy-two hours. 



The cold stage of many intermittents 
severe, prolonged, and dangerous. The 
surface-heat in many remittents, during 
the stage of excitement, very intense. 
10. 

The secretion of bile often profuse in 
the early stages; the jaundice of the 
latter stages not always manifest or deep. 

11. 

The tongue, in most instances, heavily 
coated with a white or yellowish fur in 
the early stages. 

12. 

Pains in the head, back, and limbs not 
particularly violent in most cases, and 
in many quite moderate. 

13. 13. 

Gastric irritability occasionally great, Irritability of stomach a prominent 

in the majority of cases, however, not symptom almost from the beginning. In 

such as to cause much vomiting. The many cases uncontrollable vomiting. In 



The cold stage not often severe or pro- 
longed. The surface-heat in the stage 
of excitement not particularly intense 
and sustained. 

10. 

The secretion of bile small or sus- 
pended throughout the disease, and 
the jaundice of the latter period, or after 
death, in general very conspicuous. 
11. 

The tongue variable in appearance and 
often quite natural. 

12. 
Pains of the head, back, and limbs in 
almost every case excruciating. 



356 



THE PRINCIPAL DISEASES OF THE 



stomach generally tolerant of medi- 
cines. 

14. 
The blood often sizy in remittent cases, 
and always coagulating firmly. 

15. 
Hemorrhages exceedingly rare in any 
stage of the disease. 



16. 
The secretion of urine not more sup- 
pressed than in the ordinary phlegmasia. 
17. 
The discharge of a dark-colored fluid 
from the stomach, even in fatal cases, a 
rare phenomenon. 

18. 
In fatal intermittents, the patient does 
not die in the intermission, but during the 
paroxysm. In fatal remittents, dies on 
the cessation of febrile action, which in 
many cases assumes a typhoid type for 
some time before death. 



the progress of all, great intolerance of 
medicines and drinks. 
14. 

The blood generally deficient in size, 
and in most cases the coagulum soft and 
tender. 

15. 

Hemorrhages a characteristic symp- 
tom — often commencing in the hot stage 
— scarcely ever absent in the last stage 
of bad cases. 

16. 

The secretion of urine very often greatly 
reduced, sometimes entirely suspended. 
17. 

Black vomit an almost universal pre- 
cursor of death ; when none is ejected, 
generally found in the stomach or bowels 
after death. 

18. 

Runs a course of two or three days, 
when the febrile symptoms cease, and the 
patient lies as if in the apyrexia of an 
intermittent, for an equal, a shorter, or 
a longer period, without any recurrence 
of fever, when he either dies with black 
vomit, or rapidly convalesces. Scarcely 
ever displays a train of typhoid symp- 
toms. 



TREATMENT. 

19. 19. 

The sulphate of quinine administered in The sulphate of quinine, given on the 

the intermission, or after free bleeding, decline of the hot stage, does not avert a 

in remittents, puts an end to the fever, fatal issue, except in those epidemics 

Can avert a fatal termination. which display an intermitting character. 

PATHOLOGICAL ANATOMY. 

20. 20. 

Lesions of the spleen common, and Lesions of the spleen rare. Of the 
highly characteristic, — of the gastro-en- mucous membrane of the stomach or 
teric mucous membrane, less frequent. bowels exceedingly frequent. 



SEQUELS. 



21. 



21. 

Jaundice, dropsy, hemicrania, and Sound health, often an improved state 

other intermittent neuralgias, with en- of the constitution generally follows an 

larged spleen, common consequences. attack. 



MORTALITY. 



22. 



22. 



Not self-limited, and subject to arrest 
by known treatment, if employed in due 
time. The mortality in private practice 



Self-limited ; susceptible of mitigation 
or aggravation by art ; in private prac- 
tice, private and naval hospitals, and on 



INTERIOR VALLEY OF NORTH AMERICA. 357 

is not known ; that it is small may, how- ships, taken together, the rate of mor- 

ever, be surmised from the statement tality, as we have just seen, one out of 

made in Book II. Part I. Chapter X. 5-320; the same in connection with the 

According to the reports of Charity Hos- Charity Hospital, one out of 2-323; in 

pital, stated in Book II. Part II. Chapter the Charity Hospital alone, one out of 

II., the mortality is one out of ten. two. 

These diversities appear to mark autumnal fever and yellow fever as 
distinct diseases, depending on different remote causes. These causes, how- 
ever, sometimes seem to act on the system at the same time, reciprocally 
modifying each other's effects. In this there is nothing incredible or pecu- 
liar to them. In the year 1834, at Cincinnati, the characteristics of epi- 
demic cholera were intimately blended with those of autumnal fever ; and 
as I have already stated, that fever is often modified by a typhous constitu- 
tion of the atmosphere. In the year 1832, yellow fever and epidemic 
cholera, according to Dr. Halphen and other physicians of New Orleans, 
were manifestly blended, although their remote causes were as manifestly 
very distinct. With such ascertained facts to guide us, the conclusion 
seems almost irresistible, that intermittent yellow fever is a hybrid. 



PART THIRD. 

TYPHOUS FEVERS. 



CHAPTER I. 

INTRODUCTION— GENERAL EPIDEMIC TYPHOUS CONSTITUTION. 



SECTION I. 

INTRODUCTION. 

I. Our physicians, from the Gulf of Mexico to Lake Superior, or at least 
to the northern limits of autumnal fever, are familiar with the train of 
what, in their common parlance, are called nervous or typhoid symptoms, fol- 
lowing, now and then, on cases of that fever ; which, beginning with a remit- 
ting, ends with a continued type. We are all moreover witnesses of 
the fact, that in some autumns a much greater proportional number of such 
cases occur than in others. In these secondary affections, we have the 
archetype, as far at least as symptoms are concerned, of the primary forms of 
fever, which we are now about to study. 

II. These forms, known under the name of typhus mitior, typhus gra- 
vior, and typhoid fever, which I shall group together under the term 
Typhous Fevers, are likewise met with from the Gulf to Hudson's Bay, ex- 
tending many degrees further north than our autumnal fever. Indeed they 
seem more especially to belong to the North than to the South. Their base 
line may be said to be in a high latitude and elevations, as the base line 
of autumnal fever, and yellow fever, is in a low latitude and near the level 
of the sea, and, as we advance to the south, they become rarer, just as the 
latter fevers become rarer in advancing to the north. Nevertheless they do 
not appear actually to cease even at the Gulf of Mexico ; and may be said, 
therefore, to possess a greater geographical range than our autumnal endemics 
or periodical fevers. 

III. Typhous fevers resemble autumnal fevers in appearing either spora- 
dically or epidemically; and invading both town and country, like both 
autumnal and yellow: they are not limited to a particular portion of the year, 
that between the summer and winter solstice; but occur, though unequally, 



THE PRINCIPAL DISEASES OP THE 'INTERIOR VALLEY. 359 

in every season. On the whole, however, they are most prevalent in 
autumn and winter. 

IV. For the phrase typhous fevers as a generic expression, there is no 
difficulty in giving a definition by the symptoms; but when we would con- 
struct species and assign either symptomatic or pathological characters, the 
task is very different. The common distinction into typhus and typhoid 
fever, when a systematic writer attempts to assemble and place side by side 
the characteristic symptoms of each, is not very obvious; and even when 
the diagnosis is reserved till a post-mortem inspection is made, the conclusion 
is not always satisfactory. Of course then the historian who has of necessity 
to be guided by the facts which are presented in the reports of our physicians, 
will in many cases be quite unable to say, whether the epidemic he is de- 
scribing should be denominated typhus or typhoid. Nor can it be, I suppose, 
of much practical importance under which head he arranges them. Modes 
or varieties of fever which resemble each other so closely in the circumstances 
under which they prevail, their symptoms, and the treatment they require, 
as to render a distinctive diagnosis difficult, can scarcely be regarded in 
any other light than as mere varieties ; and, although, when well charac- 
terized, it may be very proper to designate them by different names, we 
should not forget, that the terms employed express mere varieties ; as the 
words quotidian and quartan indicate varieties of intermittent fever and in- 
flammatory and congestive varieties of remittent autumnal fever. With this 
view of the difficulties of the case I shall regard synochus adynamic fever, 
typhus mitior, typhus gravior, and typhoid fever, as constituting a natural 
group ; and while in the course of this article I may frequently employ each of 
these terms, I shall generally designate the whole or any part by the ad- 
jective typhous. We shall in vain seek for a term more expressive of the 
pathological condition of the functions generally, in these forms of fever, 
than that which presents the vital properties of the organism, as stupefied. 

V. Typhous fevers cannot be confounded with any of the forms of autum- 
nal fever when both are well developed. Those which are denominated 
malignant or congestive, although as fatal as the most destructive typhous 
fevers, manifest themselves hj very different symptoms ; nor does yellow 
fever approach, in its phenomena, with the single exception of its continued 
type and its hemorrhages, any nearer to the true typhous character. They 
cannot, moreover, be identified with the veritable eruptive fevers, notwith- 
standing many cases present an eruption, or what in common language is 
called so. Still all the fevers which have been enumerated are found to be 
modified by what is called typhous atmospheric constitution ; which is like- 
wise true of pneumonia and other phlegmasia. 

VI. Were the plan and objects of this work those of a systematic elemen- 
tary treatise, equally applicable to all countries, a chapter on typhous fevers 
might be constructed out of published facts, which are the common property 
of the profession, in connection with the experience of the author; and 



360 THE PRINCIPAL DISEASES OE THE 

its excellence would be according to the extent of his researches, his care in 
the selection of facts, his skill in their arrangement, and the correctness of 
his deductions. Such a work would be proper for the pupil while engaged 
in the study of special pathology and therapeutics, not less than for the 
practical physician. My object, however, is to present these fevers as they 
prevail in the Interior Valley, by the light of their own phenomena ; and 
the results of the treatment by which they have been met : yet I propose 
to borrow from other countries such facts as may supply deficiencies in their 
etiological, pathological, and therapeutic history. 

In treating of autumnal intermittent, remittent, and yellow fevers, the 
facts and observations furnished by our own country were nearly sufficient 
for a full history, including all the methods of treatment found efficacious 
elsewhere ; but as typhous fevers are less endemical with us than the fevers 
just named, it will be necessary, in attempting to meet the requirements of 
practice, to increase our references to the foreign works. It will be my 
aim, however, so to use the exotic, as to give the indigenous as much promi- 
nence as possible. 

In proceeding to the execution of this task, there are two modes which 
may be pursued : first, to combine the facts presented by our original ob- 
servers, whether in print or in my own manuscript collections, into a sys- 
tematic treatise j or second, to give the whole of the different accounts, and 
then to subject them to the proper generalization. I have adopted the latter 
mode, believing it best fitted to show the influence of our climates, soils, and 
states of society on the production and character of these fevers, objects 
which I desire constantly to keep in view. 

VII. Before closing this introduction it may be useful to give an 
extended group definition of the fevers we are about to study. Typhous 
fevers are sometimes sporadic, but more commonly epidemic; in general 
the epidemy is local; occasionally extensive. The forming stage, with a 
few exceptions, is protracted and characterized by signs of debility in the 
organism at large ; the stage of reaction shows a continued type, and, with 
evening exacerbations, may continue for forty, sixty, or even ninety days ; 
the appetite is impaired, and the bowels sometimes torpid, are in most 
cases irritable, with a tendency to diarrhoea; the discharges seldom show 
increased, often diminished secretion of bile, and are extremely fetid ; the 
tongue becomes dry, and sordes collect on the front upper teeth ; the pulse 
is unnaturally frequent and rarely tense ; the heat of the surface is some- 
times burning, and the cheeks flushed; the eyes become dull and occasion- 
ally bloodshot; drowsiness sooner or later supervenes, with mild, and 
muttering delirium : coma is almost universal ; subsultus tendinum, espe- 
cially of the arms, manifests itself, with efforts to catch and grasp imaginary 
objects: sudamina, petechise, and rose-colored maculae, frequently appear; 
borborygmus is common, and a tympanitic condition of the bowels occa- 
sional ; early bleeding from the nose may happen, and there is sometimes 



INTERIOR VALLEY OF NORTH AMERICA. 361 

copious hemorrhage from the bowels ; in many cases, inflammation of the 
intestines, lungs, or brain, becomes associated with the fever. When these 
symptoms, or a majority of them, are present, the fever is typhus; when no 
other form of disease has preceded it, the fever is an original typhous ; when 
the disease began as an autumnal remittent, an eruptive fever, or a phleg- 
masia, the symptoms which have been enumerated indicate a secondary 
typhous ; or what has long been called the typhoid stage of the primary 
disease. 

VIII. Our typhous fevers, as already stated, generally occur as local 
epidemics. I have witnessed but one general prevalence — one wide-spread- 
ing and enduring typhous atmospheric constitution ; and before proceeding 
to speak of local and limited visitations, I propose in the next section, to 
sketch an outline of the chronology, geography, and character of that in- 
vasion. 



SECTION II. 

A GENERAL TYPHOUS EPIDEMIC CONSTITUTION. 

As might be expected, the area of the Interior Valley is so extensive, 
that as yet no true and unmixed typhous contamination of its whole atmo- 
sphere has ever occurred. The only approach to it was that which in its 
progress generated the pneumonia typhoides of 1813 and 1815, and did not 
entirely cease till several years after the latter period. Let us take a view 
of its progressive chronology, geography, and modifications. 

Of what might have occurred among the scattered settlements of the 
great region stretching from the shores of Lake Ontario to the delta of the 
Mississippi during the first ten years of the present century, we know very 
little, as the physicians of those infant communities have left but few memo- 
rials behind them within that period. According to the medical historians 
of New England, a malignant or pestilential epidemic began in the basin 
of the Connecticut River, in the state of Massachusetts, in the open town of 
Medfield, about the latitude of 42°. It was first observed in the month of 
March, 1806. To show its typhous character I shall give an abstract of its 
symptoms as then observed by Drs. Danielson and Mann.* 

" Without any apparent predisposition, the patient is suddenly taken with 
violent pain in the head and stomach, succeeded by cold chills, and followed 
by nausea and puking ; matter discharged from the stomach of no unusual 
or morbid appearance; respiration short and laborious; tongue a little 
white toward the root, and moist ; velocity of the blood increased, with a 
very sensible diminution of momentum in the radial, while in the carotid 
arteries, it was much augmented; and in a child of fifteen months old, a 

* Treatment on a malignant epidemic commonly called Spotted Fever.— By Elisha North, p. 90. 



362 THE PRINCIPAL DISEASES OF THE 

very violent pulsation was discovered at the fontanelle (opening of the head) ; 
the eyes have a wild vacant stare, without much, if any appearance of in- 
flammation ; the heat of the skin soon becomes much increased, yet the 
skin is not remarkably dry ; these symptoms are accompanied by a peculiar 
fearfulness, as if in danger of falling from the bed or the nurse's arms, and 
continue from six to nine hours, when coma (suppression of sense and 
voluntary motion) commences, with increasing debility ; extremities become 
cold ; livid spots, resembling petechias (purple spots, which appear in the last 
stages of certain fevers) appear under the skin, on the face, neck, and ex- 
tremities; pulse small, irregular, and unequal; spasms occur at intervals, 
whkh increase in violenceand frequency in proportion as the force of the cir- 
culation decreases; at this time the eyes appear glassy, and the size of the 
pupil varies suddenly, from almost wholly obliterating the iris, down to the 
size of a millet seed, and then again as suddenly dilating. These symptoms 
seem to mark the second period of the disease, and continue from three to 
five hours. The third and last stage is distinguished by a total loss of pulsa- 
tion at the wrists; livid appearances become more general, spasms more 
violent; coma more profound ; death ! The patient has in general continued 
in the last stage from six to twelve hours." 

Early in the following year, 1807, the epidemic made its appearance in 
many other towns of Massachusetts and Connecticut ; and it may not be 
unprofitable to transcribe an account of its symptoms, as it occurred in the 
county town of Winchester in the latter state. According to Dr. Wood- 
ward they were as follows : — * 

" Young people under the age of twenty, were most liable to it ; and 
among adults, females are more liable than males. No age nor sex, how- 
ever, were free from the attacks; it assumed, in different subjects, all grades 
of disease, from a mild fever to a perfect plague. The symptoms were 
various, according to its inveteracy. It attacks with lassitude, chills, great 
prostration of strength, eyes red and watery, pupils dilated in some cases, 
in others small, like dying persons'; often delirium, with exquisite pain in 
the head ; great anxiety at stomach, with tossing of the body ; nausea, and 
often a troublesome vomiting ; a pain and lameness in some of the limbs 
often ushered in the disorder ; there was a soreness of the flesh, and gene- 
rally spots on the skin, the size of half a common turkey-shot, were scattered 
over the body, resembling blood-blisters ; likewise, efflorescences, of various 
sizes and shapes, in different parts, which were dark or florid; and a dark 
or light color of the spots and efflorescences gave a clue to a favorable or 
unfavorable prognosis. The darker the more dangerous. In some, after the 
chills, there was great heat, which was of the thrilling, stinging kind. The 
pulse, like other symptoms, was various, sometimes considerably full, but 
generally very weak, quick, and irregidar. The disease sometimes in this 
season, assumed the inflammatory type, sometimes the synochous, but gene- 

* Treatment on a malignant epidemic commonly called Spotted Fever.— By Elisha North, p. 112. 



INTERIOR VALLEY OF NORTH AMERICA. 363 

rally the typhous. The violent symptoms were great lassitude, with universal 
pains in the muscles; chills; heats, if any, were of very short duration ; un- 
usual prostration of strength ; delirium, with severe pain in the head ; vomit- 
ing, with indescribable anxiety at the stomach ; eyes red and watery, and 
rolled up, and the head drawn back with spasm ; pulse quick, weak, and 
irregular; petechia and vibices all over the body, and a cadaverous counte- 
nance and smell : death often closed the scene in ten or fifteen hours after 
the first attack ; some, however, survived all these symptoms ; those who 
died appeared to sink away under the load of disease, became cold and low, 
and died comatose, with all the marks of general mortification ; others went 
off suddenly, apparently apoplectic. The body, near the fatal period, and 
soon after, became as spotted as an adder, and demonstrated a general dis- 
solution of the .fluids. Those who survived these symptoms appeared to 
owe their life to a very liberal use of strong stimulants and tonics ; and 
when the vital flame began to be rekindled in the system some grievous ex- 
ternal affection most certainly appeared, such as inflammations of the joints, 
like the acute rheumatism, or an erysipelatous affection of the skin, or rack- 
ing pains, without any morbid external appearance, convulsions, spasms, &c. 
Those external affections often proved very lingering and tedious, and in 
some instances quite exhausted the patient. This, however, generally 
proved a manageable state of the disease, and~ rather to be desired than 
feared." 

In the following spring and early summer (1808), according to the same 
author, the disease invaded many other towns of the states just mentioned, 
with symptoms considerably different.* 

" An eruption on the skin so seldom appeared, that it could no longer be 
considered a characteristic symptom of the disease. Those spots, the size 
of half a shot, resembling blood-blisters, have not appeared in those cases 
which I have seen; and those inflammations of the joints above mentioned 
are now seldom noticed. All the attacks for a year past, which I have seen, 
are of the low typhous kind." 

Continuing to reappear every fall, winter, or spring, of the years 1809, 
'10, '11, and '12, it scourged various parts of New England and New York. 
In the two or three latter years, but especially in the last, it underwent a 
change of character, which led some physicians to regard it as having been 
superseded by a different epidemic constitution, a conclusion, however, to 
which I cannot assent. This change procured for it a new appellation — 
pneumonia typhoides. Even as far back as 1810, at one locality in Vermont, 
it was denominated malignant pleurisy, f and in 1811, Dr. Hazeltine, of the 
state of Maine, saw it assume the character of " malignant pneumonia." J 
It was not, however, till 1812, that the pneumonia complications became 
general. In that year, the physician just quoted saw both diseases prevail- 
ing at the same time, and running into each other in such manner as to 

* Ibid. p. 118. f Am. Med. & Phil. Reg. vol. iv. p. 38. % Med. Repos. vol. xviii. p. 26. 



364 THE PRINCIPAL DISEASES OF THE 

present every intermediate grade between the violent cerebral symptoms of 
spotted fever on the one hand, and the equally severe pulmonary symptoms 
of pneumonia typhoides, on the other. 

With this change of character came an increased impulse of diffusion, and 
in the autumn of 1812, the epidemic, overleaping the mountains and high- 
lands which had hitherto kept it on the Atlantic plain, fell upon that of the 
interior, and thenceforward became one of the diseases falling properly 
within the sphere of this work. Its entrance within our prescribed geo- 
graphical limits was by Lake George and Lake Champlain, in the western 
part of Vermont, and the northeastern corner of New York. Its invasion 
of the Great Valley, in that memorable year, was not, however, limited to 
those sections, and leaving them for the present, let us inquire into its de- 
velopment in other parts. 

In a valuable inaugural thesis,* Dr. Ludlow has embodied, with his own 
observations, those of Drs. Carter and Vanderburgh, of Geneva, and Dr. 
Hayes, of Canandaigua, Western New York, on the epidemics of that region, 
through a long series of years. 

The settlement of that country commenced about the year 1791, and up 
to and including 1805, the fevers seem to have been intermittents and re- 
mittents, exhibiting but little tendency to a typhous character. But in De- 
cember, 1806, a fever of a typhous character broke out at Palmyra. It gene- 
rally proved fatal in three or four days, being attended in the beginning 
with great prostration, and near the close, with coma, subsultus tendinum, and 
hiccough. In the summer of 1807, the fevers were inflammatory, but in 
autumn assumed a typhous form, and manifestations of an epidemic con- 
stitution of that kind were made in various parts of that region. For the 
first four months of the following year, 1808, a typhous fever continued to 
prevail, and for the remainder of the year, the fevers generally assumed a 
continued type. The fever of 1809 showed but little inflammation, and 
readily assumed the form of a mild typhus. Throughout 1810, the fevers 
had nearly the same character, but were less prevalent. In 1811, the mani- 
festations of a typhous constitution appeared to be suspended by an ex- 
tremely warm and dry summer, generating bilious fevers. The following 
winter, 1811-12, was intensely cold, and pneumonia was among the preva- 
lent diseases. In the month of March, 1812, pleurisy exhibited a great 
variety of characters, and often demanded the most opposite treatment. In 
the months of April and May, a few sporadic cases of pneumonia typhoides 
(the first ever known in that quarter), presented themselves, and after sus- 
pension during the summer, reappeared in autumn, affecting the people, but 
more especially the troops, at Lewistown, on the Niagara River. In the 
months of January and February, 1813, the disease became general through- 
out that region. On the access of warm weather, the epidemic ceased, but 

* Observations on the Lake Fever and Other Diseases of the Genesee Country, in New York, 1823. 
By E. S. Ludlow. 



INTERIOR VALLEY OF NORTH AMERICA. 365 

returned with mitigated violence the ensuing winter, 1814-15. In the 
spring of 1815, it disappeared. The remainder of that year, and the 
calendar years 1816 and most of 1817 were free from typhous diseases; 
but in the autumn of the latter, a " fever with typhoid symptoms prevailed 
to a limited extent," and recurred in December, 1818. From that time to 
1822, when the chronicle terminates, no typhous affection occurred. 

We must now turn to another part of the Valley, and trace out the rise 
and progress of the epidemic distemperature. 

My opportunities for personal observation (as a student of medicine at 
Cincinnati), began in the year 1800, twelve years after its settlement. Of 
its epidemic diseases during those years, I have but little information. Dr. 
Allison, who had been surgeon-general of the armies of St. Clair and Wayne, 
whose headquarters were here, informed me that there had been but one 
typhous epidemic constitution from the second winter of the settlement of 
the town, and then it lasted for that winter only. From 1800 to 1808, the 
general type of fever in the town and surrounding country was intermittent 
and remittent, occasionally, as everywhere and in all autumns, presenting 
cases which assumed a typhoid character. But a change of epidemic con- 
stitution, a new atmospheric contamination, was at hand. In the month of 
December, 1809, a typhous fever — some cases of which corresponded suffi- 
ciently well with the typhus gravior of Cullen, while the majority resembled 
his synochus or typhus mitior, broke out in the western part of the town, 
and in several instances proved fatal. In January, it continued to prevail, 
and almost every form of disease appeared to be modified by it. Diarrhoea 
and hemorrhages from the bowels were common symptoms, the pulse was 
generally soft, subsultus tendinum, coma, and muttering delirium were fre- 
quent; a few cases presented petechise, and a greater number sudamina, 
which sometimes assumed a purulent aspect. A strong tendency to gan- 
grene in the blistered surfaces was common. In many instances there was 
a manifest affection of the lungs. 

After the month of January, scarcely any cases occurred till the follow- 
ing August, 1810. In September new cases appeared, and in October, I 
had a fatal case that from the beginning was attended with the rare combi- 
nation of diarrhoea, cough, and difficulty of breathing. Although the blood 
drawn was sizy, the pulse and general strength of the patient sunk rapidly 
under its loss. In short, it was a well-marked specimen of pneumonia ty- 
phoides. Cases of a typhous character continued to occur in November and 
December. The early part of the next year, 1811, brought forth a number 
of cases of the same kind, but the months of May, June, and July, were 
exempt. In August the disease reappeared, and continued to occur to the end 
of the year, in both town and country. In the early months of the next year, 
1812, cases still occurred, but in the spring the disease ceased, and did not 
reappear till August, when occasional cases began, and continued to recur' 
throughout the remainder of the year. During this time, a typhous fever 



366 THE PRINCIPAL DISEASES OF THE 

prevailed more or less in the army of General Hull at Detroit. In the month 
of September, an officer, Lieutenant Mansfield, seized as he was returning home, 
in this city, after the surrender of the army, died with the characteristic 
symptoms of a typhous fever. At several of the posts between this place 
and Detroit, a typhous tendency was manifest. The first four months of 
1813 presented cases of the same fever complicated with pulmonic inflam- 
mation, which required the lancet, but again it abated till August, when it 
recurred with more violence and mortality than in its outbreak in 1809; 
affecting moreover a much larger number. This state of things continued 
to the end of the year. During this period many dangerous pulmonary af- 
fections occurred, a number of which, in the adjacent country, were of an 
alarming nature. In fact these were cases of pneumonia typhoides, which 
established itself in the country before it did in the city, although the epi- 
demic typhous constitution appeared first in the latter. 

Thus the epidemic, which, as we have seen, reached the shores of the Lakes 
Ontario and Erie in the winter of 1812-13, did not begin on the banks of 
the Ohio till that of 1813-14. Its prevalence, moreover, was not then very 
great, and in the following summer it nearly ceased. In the winter of 
1814-15, however, it returned with violence, and was really epidemic. 

In the years 1818 and 19, many cases of typhous fever occurred at Cin- 
cinnati, as in the Genesee country, since which no epidemic constitution 
of that kind has occurred in the city. 

By a communication from Dr. Hildreth, of Marietta, in this state, I learn, 
that from 1812 to 1820, a " typhous atmospheric constitution" prevailed in 
that town and the surrounding country. In the spring and summer, the 
disease took the form of typhus mitior ; in autumn and winter, it often 
appeared of a malignant character, approaching the typhus gravior of 
Dr. Cullen. The former was generally manageable — the latter commonly 
fatal, from implicating the brain. 

At Shepherdsville, Kentucky, N. L. 38°, the epidemic made its appear- 
ance in the winter of 1813 and 14, and prevailed as an epidemic till the 
ensuing June. In the following winter, the fever reappeared, but was only 
sporadic* 

I spent the year 1806, in Mason County, Kentucky, and witnessed a local 
epidemic in the village of Mayslick, where fevers of every kind had from 
its first settlement been extremely rare. Most of the cases, in the begin- 
ning, were marked with remissions and bilious discharges ; but the fever 
did not commence till after the usual time of the onset of periodical fever, 
and continued till December. Moreover, nearly every case was marked, in 
its latter stages, with the symptoms of typhus, showing that the epidemic 
constitution which had then begun with so much violence in New England, 
was, also, forming in the West.f 

Having traced out the development of this epidemic on the banks of the 

* On the Med. Top. of Shep. By W. Jewell, M.D. p. 29. f Barton's Journal for 1808, p. 85. 



INTERIOR VALLEY OF NORTH AMERICA. 367 

Ohio, in the latitude of 39°, let us go further south. Dr. Kerr* informs 
us, that in the month of December, 1813, while a portion of the United 
States Army was in the woods of Eastern Mississippi, some cases of the 
same fever occurred. The following winter he spent in Natchez, and, in the 
months of March, April, and May, he saw several cases, some of which 
proved fatal in twenty-four, forty-eight, or sixty hours. When they con- 
tinued longer, the type of the disease became decidedly typhous. In 
February and March, 1815, the disease, displaying a still higher pneu- 
monic character, occurred in both town and country. 

According to Dr. Huestis,f the epidemic began among the troops sta- 
tioned in New Orleans, about the middle of April, 1814. It does not 
appear to have been preceded by any other form of typhus fever, as in 
New England, Western New York, and at Cincinnati ; yet the Doctor re- 
garded it as having much in common with the spotted fever of the former, 
while in the pulmonary lesions, it displayed a perfect identity with the 
pneumonia typhoides, which began two years before among the troops on the 
northern lakes, leaving no doubt that it was indeed the same epidemic. 

I have thus traced out the rise, progress, and decline of the only general 
typhous constitution of the atmosphere, which has invaded the Interior 
Valley. The citations of authority are not so numerous as could be wished; 
but it is matter of tradition that all parts of the Valley were more or less 
affected, although the published accounts are so few in number. In many 
places besides Western New York and Cincinnati, the pneumonia typhoides 
was doubtless preceded by cases of simpler typhus, of which no history 
can now be obtained. It has been fashionable to regard pneumonia 
typhoides as inflammation of the lungs from cold, occurring in constitutions 
acted on by the cause of typhus ; but we are scarcely justifiable in contem- 
plating the epidemic under that aspect; for the number of cases was much 
greater than the number of pneumonic cases before and after the reign of 
that epidemic, and in some years they continued to occur till near mid- 
summer, long after the season for pulmonary inflammation had passed by. 
We should, I think, rather regard the fever as having a strong tendency to 
localize itself in the lungs. In every place, however, cases occurred without 
any pulmonary complication. 

I have spoken of this epidemic constitution as dying away about the 
year 1820 ; but this is not rigorously correct. The occult cause, it is true, 
might have become extinct, but its impression on the systems of the people 
seems, from the facts I am about to state, to have remained. It is well 
known as a part of the history of our periodical, or autumnal fever, that it is 
more prevalent and fatal over large tracts of country in some summers and 
autumns than others. Now of all the years which have elapsed since the 
first settlement of the Valley, 1821, 1822, and 1823, but especially 1822, 
were the most sickly. Cincinnati suffered, and boats returning from the 

* Med. Rep. vol. xviii. p. 211. f Hays. Obs. and Med. Tracts and Research, of Louisiana, 1817, p. 143. 



368 THE PRINCIPAL DISEASES OF THE 

lower country constantly brought up cases of fever of obstinate and dangerous 
character. Dr. Hildreth, in the communication from which I have just 
quoted, observes : " The autumnal epidemic of 1822 was introduced by a 
number of cases of malignant typhus, attended with glandular swellings, 
mostly parotid ; but after the bilious epidemic autumnal fever was fully 
established, every other disease disappeared before it." The towns along 
the Ohio River were at that time comparatively few ; but all, or nearly all, 
suffered. The Swiss village of Vevay, Indiana, was nearly depopulated; 
and the capital of that state, Indianapolis, suffered in nearly the same 
degree.* Louisville, and the towns on the opposite side of the river, were 
severely visited — the first especially was scourged almost to desolation. f 
The state of Kentucky generally, but especially its southern half, was 
fatally invaded. Columbus, Mississippi; Cahawba, Alabama; Pensacola, 
Florida ; Baton Rouge, Louisiana, all suffered in like manner. This is 
proved, as regards the two latter places, by the army returns, which also 
show that the sickness, " alarmingly mortal" at Fort Smith on the Ar- 
kansas, extended to Council Bluffs far up the Missouri. J 

These notices, which might have been introduced under the head of Au- 
tumnal Fever, come in more properly here, as they seem to show that the 
fevers of those years were the joint offspring of the typhous and the bilious 
epidemic constitutions. At least I know not of any other cause for the 
striking mortality of our autumnal fever during that period. The sulphate 
of quinine had not then come into general use in the Valley, and its control 
over autumnal fever was not fully understood. 



CHAPTER II. 

LOCAL HISTORIES OF OUR CONTINUED OR TYPHOUS FEVERS- 
SOUTHERN BASIN APPALACHIAN MOUNTAIN REGION. 



SECTION I. 

SUB-EPIDEMIC AND SPORADIC VISITATIONS. 

I HAVE visited many portions of the Appalachian Chain, from the 43d 
down to the 34th parallel of latitude, that is, from New York to South Caro- 
lina inclusive. There are many crests and peaks which rise from 4000 to 6000 
feet above the level of the sea; but the elevated portions are not inhabited; 
and the valleys and enclosed table lands, which are peopled, generally lie 
at an elevation varying from 1500 to 2500 feet. The higher declivities 
are, however, not without inhabitants, generally of the poorer classes, and 

* See toI. i. p. 311, No. 4. t Ibid. P- 2i9 > No - 4 - 

X Stat. Rep. of the Sick, and Mort. TJ. S. A. 1840. 



INTERIOR VALLEY OF NORTH AMERICA. 369 

thus, we have a sparse and limited Alpine population, at the altitude of 
3000 feet. The ridges and summits which tower so high above the peopled 
valleys and pastures, modify the climate of the latter, and make it very 
different from what.it would be if a great mountain plain or table-land 
existed 5 for they condense the vapor of the atmosphere, preventing a high 
dew point, and securing abundance, of rain; while they act as coolers, and 
repress a high temperature, or at least limit it to a brief period of the sum- 
mer day. It has been already stated,* that in this Alpine region, intermit- 
tent fevers are almost unknown ; and that remittents tend to a continued 
form. In fact, they may be said to assume a typhous character. The 
copious secretion of bile, the distinct remissions, and the occasional trans- 
formation into intermittents. which they present in the same latitudes at a 
lower level are here seldom seen j yet the season of the year in which they 
prevail most, August, September, and October, mark them as the climatic 
equivalents of the remitting fever of the low, warm plains and valleys 
between the mountains and the Mississippi. They are sometimes arrested 
by the treatment which cures the latter; but more commonly take a pro- 
tracted course, and display the symptoms which all concur in denominating 
typhous. 

But in addition to these sporadic, typhous, autumnal fevers, which con- 
stitute a sort of connecting link between the periodical and continued fevers, 
the mountain localities are sometimes invaded with sub-epidemic typhous 
fevers, a few visitations of which I shall proceed briefly to describe. I begin 
in the North, for it seems as natural to proceed from the higher to the lower 
latitudes in describing the continued fevers, as from the lower to the higher 
in studying the periodical. 



SECTION II. 

SUB-EPIDEMIC AT ELLIOTTSVILLE, NEW YORK. 

I. This town is situated in a beautiful expansion of Great Valley Creek, 
which opens into the Allegheny River. A transparent little stream, flows 
through it, but there are neither ponds nor swamps. True intermittent 
and remittent fevers are almost unknown, but sporadic cases of the latter 
terminating in a typhous stage occur every autumn. 

II. An Epidemic, as I learned from Dr. Stanton and Dr. Williams, 
commenced in the month of September, 1843. It was characterized by a 
slow access, consisting of lassitude, chilliness, loss of appetite, and loose 
bowels, with a furred tongue. When the reaction occurred, the pulse be- 
came frequent, 120 or more, was sometimes full, oftener otherwise, and 
always easily compressed. Stupor, delirium, and picking at imaginary 
objects were common. In some cases, the state of mind and senses was 

* In various parts of Book I. Part I. Book II. Part II. 

vol. ii. 24 



370 THE PRINCIPAL DISEASES OF THE 

nearly that of delirium tremens. The eyes were occasionally red. In a 
week or more, the coat of the tongue fell off, and the organ then assumed, 
first a red and then a dark and dry aspect. Several patients had hemor- 
rhages from the bowels after the second week. Few cases terminated till 
after the third week, and many ran on till the sixth, eighth, or twelfth 
week, when they generally recovered. No maculae were observed. Neither 
venesection nor the sulphate of quinine was found beneficial in the treat- 
ment of this fever. Gentle laxatives, diaphoretics, diluents, mucilages, 
cold applications to the head, blisters to the neck, and sinapisms to the abdo- 
men, with brandy and capsicum in the advanced stages did best. 

Young persons, males more than females, were the chief subjects of this 
fever. Dr. Stanton estimated the number of cases at 200 out of a popula- 
tion of 700. There were from 15 to 18 deaths ; none of which were followed 
by a post-mortem inspection. 

The onset of this epidemic was sudden and its spread rapid. It continued 
till the winter, and throughout that season violent changes of weather 
were immediately followed by new cases. To the south and north of this 
place it extended to the distance of 20 or 30 miles, and much further to 
the east, but I have not facts to complete its topographical history. No 
cause could be assigned for this epidemic — there was no evidence of its 
being imported or of its extending by contagion. Dr. Williams had resided 
in the place 15 years before this visitation, and informed me that it was the 
first. When I was at the place four years afterward, it had not been re- 
peated. 

SECTION III. 

SUB-EPIDEMIC AT PARISBURG, VIRGINIA.* 

I. When atParisburg in 1850 1 was informed by Dr. Peck and Dr. French, 
that a fever of a continued and typhous character had prevailed for several 
years in Tazewell County, adjoining on the west to Giles County, of which 
Parisburg is the county town. Making its way into Giles County it spread 
along the whole course of Sinking Creek, which enters New River a few 
miles above Parisburg. In the autumn of 1845 it began in that town ; 
yet apparently from a different source. An emigrant from North Carolina 
arrived with the fever, of which he died. Soon afterwards, a number of 
cases occurred, but they were not traced up to communication with him. It 
did not become epidemic till winter, when it spread into the adjoining coun- 
try in all directions. Four deaths occurred in the village. The victims 
were all adults. It was milder in children than grown persons. It ceased 
on the access of hot weather, and did not return the ensuing autumn upon 
the people of the village, but reappeared among those of the country. The 
following facts have a bearing on the question of contagious propagation. 

* See vol. i. p. 262, No. V. 



INTERIOR VALLEY OF NORTH AMERICA. 371 

Dr. Peck informed me, that a man who lived far up Sinking Creek, at an 
elevation of more than two thousand feet, where the fever had not occurred, 
visited a family laboring under it lower down that stream. He remained 
with them nearly two days and returned home. In about a week he was 
attacked with the same fever, and the various members of the family in 
which he resided were soon after seized with it — no less than four being 
affected at one time. 

From the physician just named, I received another history, which has the 
same bearing. In the summer, one of his negro women visited a family near 
the village, which had lately suffered from the fever. A few days after- 
wards she was seized with the fever, which at the beginning manifested many 
bilious symptoms, but became typhous and protracted. While laboring under 
it, she was removed to his father's, six miles in the country. A week after 
her arrival a negro woman who had slept in the same cabin with her was 
taken down and died, the other recovering. The husband of the first occu- 
pied the same room, and was next attacked, but recovered. Next, in another 
apartment of the same cabin, two negroes fell sick, of whom one got well, 
the other did not. About sixty feet from this cabin, there was another 
negro house, in which eight cases occurred. Several of the patients were 
children, who did not become very sick. Lastly, his father, who resided 
hard by, was seized with the same fever and fell a victim to it. During his 
illness many of the neighbors visited him, without contracting the disease, 
but his room was large and well ventilated, and their visits were generally 
short. 

Dr. French gave me the following fact. A young white woman went as 
a nurse to the house at which Dr. Peck's servant seemed to have contracted 
the fever. She sickened with it and was taken home. Dr. French had her 
placed in a clean and well-aired room, and none of those around her expe- 
rienced an attack. Further, some members of the family visited the house 
at which she had worked, and were seized with the fever, which extended 
to individuals who had not been there, until the whole of the family, five in 
number, were taken down. 

II. The forming stage of this fever was protracted, in some cases to two 
or three weeks. The whole duration of the fever was sometimes twelve 
weeks. The local affections as indicated by the symptoms were, in different 
cases, seated in the head, bowels, and lungs, the last occurred generally in 
the winter. In some patients the head and bowels were both disordered at 
the same time. Hemorrhage from the bowels happened in a number of 
patients. Tenderness in the right iliac region existed in a number of patients, 
but tympanitis was rare. The tongue, at first covered with a moist yellow 
fur, at length became clean, dry, and brown; corresponding with which 
there were muttering delirium and subsultus tendinum. Some cases were 
attended with profuse perspiration. Maculae were not observed, perhaps not 



3 < 2 THE PRINCIPAL DISEASES OF THE 

sought for. No post-mortem examinations were permitted. Many of those 
who recovered were afterwards troubled with obstinate constipation. 

III. Both my informants found bloodletting powerless as to an arrest of 
the fever, while by exhausting the patient it did harm. When bilious 
symptoms were present emetics afforded relief but did not shorten the fever. 
Active purging was injurious, by increasing the tendency to diarrhoea. Dr. 
French preferred rhubarb and carbonate of soda to any other aperient. 
Dr. Peck directed copious injections of warm water, with advantage. Ca- 
lomel in repeated doses failed to produce its characteristic effects on 
the system, and appeared to be injurious. Sulphate of quinine did no 
good. Epigastric cupping, followed with emollient poultices, proved of service. 
On the whole the disease could not be shortened; and the practice had for 
its object to alleviate particular symptoms, and support the patient's strength. 

IV. Extension to Blacksburg. — The sub-epidemic which has been de- 
scribed extended to Blacksburg, a town sixteen miles east of Parisburg, from 
which it is separated by two mountain ranges. Dr. Jackson informed me that 
in its latter stages hemorrhages from the bowels were frequent and did not 
portend a fatal issue. He employed small doses of calomel and ipecac, with 
advantage ; and poultices rendered irritating with powdered mustard, applied 
over the abdomeu proved beneficial. 

V. Extension to Christian sbtjrg. — This old town is situated at the 
source of one of the tributaries of New River, on a limestone plateau. It 
lies thirty-two miles east from Parisburg. The epidemic described under 
that head, rose in and around this town before it did in that. Dr. Edie 
saw it manifest a tendency to run through families. On one plantation, 
thirty negroes suffered attacks, and eight died. On another plantation, 
twenty negroes, all of the same blood, were seized with it, except two, who 
had experienced a previous attack. He never saw but one second attack. 
On the whole, the negroes were more affected than the whites ; and, of the 
latter, the poor suffered more than those in comfortable circumstances. He 
frequently saw it limited to a single member of a family. 

Dr. Edie saw many cases in which hemorrhage from the bowels occurred, 
and regarded it as a good, rather than a bad sign. Tympanitis was rare. 
Coma and subsultus tendinum sometimes occurred in the early stages of the 
fever, and suggested inflammation of the brain, but the progress of the dis- 
ease and the effects of medicines, convinced him at length that the organ 
was only in a state of irritation. In winter, the lungs were deeply inflamed, 
or deeply engorged. In terminating, whether in health or death, it fre- 
quently seemed to observe hebdomadal periods of seven, fourteen, or twenty 
days. In some cases it continued for nine weeks, exhibiting symptoms of 
pulmonary or enteric inflammation. 

In the treatment, he found simple measures best. Venesection appeared 
to prolong the fever. Some of those whom he bled afterwards had hemor- 
rhage from the bowels. Vomits of ipecacuanha were useful. Purging was 



INTERIOR VALLEY OF NORTH AMERICA. 373 

injurious, except when brought about with minute doses of calomel and 
ipecac, followed by small doses of castor oil. The skin was generally moist, 
and sudorifics did little good. Tepid sponging was found useful. Sulphate 
of quinine seemed to increase the heat of the system, without relieving any 
symptom, or shortening the fever. To relieve the pulmonary inflammation, 
which often showed itself first in the latter stages of the fever, he gave 
ipecac, and blue mercurial mass, cupped, blistered, and made his patients in- 
hale aqueous vapor. Of the last he thought highly. 

It is proper to add, that although the mountain ranges surrounding the 
towns and valleys which have been described are composed of sandstone, the 
latter rest on limestone. 



SECTION IV. 

SUB-EPIDEMICS IN BUNCOMBE COUNTY, NORTH CAROLINA. 

I. Medical Topography. — Not having visited this region before writing 
the topography of the first volume, I must briefly describe it here. Bun- 
combe County, and the basin of the French Broad, one of the elementary 
streams of the Tennessee River, were once synonymous, but the civil limits 
of the former have been reduced ; yet the well-known name may stand with 
the medical historian as designating a region, — that portion of North Caro- 
lina which lies west of the Blue Ridge, which is here the watershed be- 
tween the Interior Valley and the Atlantic plain. It lies between the 35th 
and 36th parallels. 

This region is in the centre of the great southern tuberosity of the Appa- 
lachian Range, which constitutes a remarkable hydrographical centre.* 
Several summits range between five and six thousand feet above the level 
of the sea, while Point Mitchell, the highest peak of the Black Mountain, 
rises to 6476. Several tributaries of the French Broad originate on the 
slopes of this mountain, and flow off westwardly through cultivated valleys, 
to enter that river by its right bank. Its general course is from south to 
north. In the centre of the mountain region, there is a valley extension, 
from 15 to 20 miles in breadth, and nearly twice as much in length, through 
which, near its western margin, the river flows. This valley, with the 
smaller ones opening into it, are the chief seats of population. Its elevation 
above the sea varies from 22 to 2500 feet; but a portion of the people reside 
at a higher altitude. Buncombe County reduced, and Henderson County 
set off from it on the south, divide this valley between them. Ashville, the 
county seat of the former, is the ancient metropolis of this Alpine region. 
Hendersonville, a young village, is the beautifully-situated county seat of 
the latter. Flat Rock is a settlement a few miles south of Hendersonville. 
Its people are almost entirely rich citizens and planters of South Carolina 

* See vol. i. p. 16, E. 



H74 • THE PRINCIPAL DISEASES OF THE 

and Georgia, who here find a summer residence which the fevers of the low 
country never reach, although they live contiguous to small streams, with 
broad, marshy, and paludal bottoms, as are many of those along the French 
Broad. 

The Buncombe region lies entirely within the great primitive formation 
of the South, and all its rocks are granite, gneiss, or mica slate. Its springs 
of course afford soft water, the temperature of which I found in the month 
of May, to vary in different places from 53° to 55° Fah. 

I cannot conclude this hasty and most imperfect sketch, without indicat- 
ing to the people of Middle Tennessee, Alabama, and Florida, the signal ad- 
vantages of a summer residence in this region, whether we refer to exemption 
from malarial fevers, to the renovation of broken-down constitutions, or to 
the enjoyment which comes from the daily sight and contemplation of grand 
and beautiful mountain scenery. 

II. Along the French Broad and its tributaries, intermittent fever is 
nearly unknown. Remittents, generally becoming continued, occasionally 
occur, but not oftener near the water-courses than at a distance from them. 
Those cases which constitute, so to speak, a connecting link between the 
periodical and the typhous fevers, have been briefly described in the first 
section of this chapter. They are the true mountain fever, sporadic at 
almost any season of the year, and sometimes prevailing to a semi-epidemic 
degree in autumn and early winter. 

Of this form of fever, Dr. Whitted and Dr. Jones of Hendersonville had 
seen very few cases in several years, although the often-inundated and 
swampy valley of Muddy Creek, a branch of the French Broad, is within 
their range of practice. Such a valley at a lower level, with springs of the 
temperature of 54° Fah., would afford much autumnal fever. Why should 
it not be the same here? At Hendersonville, the gentlemen just named 
had seen no original case of typhous fever; the experience ol*Drs. Lester and 
Ashville had been nearly the same. 

III. History. — The long residence and extended practice of Dr. J. F. E. 
Hardy, of Ashville, has presented him with facts which throw more light 
on the fevers of this elevated region. Through a period of twenty-six years, 
this observing and indefatigable physician has annually seen a remitto-typhous 
fever, which was more rife from August to November, inclusive, than at 
other times. It prevailed more in the country than the village of Ash- 
ville j and was more frequent in the early than the latter years of his prac- 
tice. The people among whom it prevailed most, lived chiefly in crowded 
and unventilated cabins, without windows. Those on the banks of the 
French Broad, and its tributaries, were not more liable to it than the in- 
habitants of the highest and driest localities. Sometimes it assumes a sub- 
epidemic character, as appears from the following observations. 

A. D. 1829. — In the autumn of this year, beginning in August and end- 
ing in November, Dr. Hardy had fifty-two cases, in eight or ten families of 



INTERIOR VALLEY OF NORTH AMERICA. 375 

one neighborhood, west of the French Broad and distributed along its tribu- 
tary brooks. They were all poor whites, living in low, close log cabins, 
generally without windows, and always with floors nearly in contact with 
the ground. A majority of each family were taken down — and in some in- 
stances, the whole. It attacked these families seriatim ; yet there was no 
known introduction of it into the first, nor any discoverable contagious 
communication. In one family, consisting of twelve persons, the fever 
attacked every member, except a daughter, twelve years old; if, indeed, she 
was an exception, seeing that she experienced a severe illness at the same 
time. 

After a day of chilliness and headache, a kind of nettle-rash broke out, 
from which there was an oozing of blood, and the wheals or whelks soon 
assumed a dark or livid color. A slight hemorrhage from the nose super- 
vened, and another from the bowels, so copious as to produce exhaustion. 
No delirium, coma, or subsultus tendinum occurred, however, and she re- 
covered in eight or ten days, under the use of calomel, opium, and sugar of 
lead, with burnt brandy toddy internally, and a bath of oak-bark decotion. 
No other member of this family had hemorrhage. 

While the fever was prevailing in this neighborhood, dysentery was rife 
in another, twelve miles further up the French Broad, and some of the 
cases assumed a typhous character. 

A. D. 1838. — In this year Dr. Hardy saw a poor white family of sixteen 
persons, who lodged in two dirty rooms, attacked with the same form of fever. 
All had it but the old man. As many as eight were down at one time. 
Some of them had hemorrhage from the nose, bowels, and tongue. Blood 
could be pressed out of the least as from a sponge. The whole recovered. 
The fever did not prevail in the neighborhood, nor was it communicated 
from this family. 

A. D. 1842. — Through the autumn of this year, beginning in the latter 
part of August, twenty-one negroes on the plantation of Mr. P. experienced 
attacks of the fever. They had been well fed with bread and meat ; but 
were lodged in crowded huts without windows, and with floors close to the 
ground. All recovered except one, a pregnant woman, who suffered abor- 
tion before death. No other family in the neighborhood had the fever ; but 
it was recollected that several years before, the negroes occupying the same 
cabins had experienced a similar attack. 

A. D. 1849. — In the month of August, a white family, in the beautiful 
valley of the Swanannoa, four miles from Ashville, charitably received a 
sick traveller from East Tennessee, whose disease proved to be continued 
or typhous fever. He recovered. There were but two rooms in the house, 
and some members of the family slept in the one where he lay. They con- 
sisted of the husband, wife, and four children, every one of whom sickened 
with the fever, and the parents died. No family in the vicinity took it. 
There were no marshes or wet alluvions where this family resided. 



376 THE PRINCIPAL DISEASES OF THE 

Dr. Hardy has never seen a general typhous atmospheric constitution. 
The fever has always prevailed, here and there, in neighborhoods, some of 
which have been high up the mountains, between 2500 and 3000 feet. He 
has slept night after night in the same rooms with his distant patients, but 
never contracted the disease. 

IV. Symptoms. — Forming stage slow and deceptious. Anorexia, foul 
tongue, chilliness, dull headache, feeble and frequent pulse, and constipa- 
tion, to which the patient generally ascribes all his bad feelings. This con- 
dition may continue for two days or a week ; when fever with a peculiar 
anxiety of countenance, parched skin, acute headache, sleeplessness and 
jactitation, supervenes; the epigastrium becomes tender, and the stools are 
either of a pea green, or clay color. The morning sub-remission is without 
moisture of the skin, and the exacerbation unpreceded by a chill ; though 
sometimes a creeping sensation occurs. The heavy coat of fur on the 
tongue soon becomes brown and dry, the organ itself assuming a pointed form 
with red edges. Delirium, wild or low, is generally present, and often com- 
mences early; coma seldom occurs till the tenth or twelfth day; subsultus ten- 
dinum is less often present, but not so frequent as the other two symptoms. 
The pupil in the early periods of the hot stage is often contracted. In 
some fatal cases the eye is red, and its expression wild without delirium. 
Sordes of the teeth and lips are common. Petechia occasionally appear in 
the latter stages. Abdominal tenderness is common : tympanitis rarer. 
Diarrhoea frequently occurs and coagula of blood are occasionally discharged. 
In some cases carbunculoid abscesses occur in the cellular tissue of the 
trunk and extremities, which discharge dark sloughs resembling coagula ; 
they are not painful, but presage a slow recovery. Dr. Hardy had not 
been permitted to make any post-mortem examinations. 

V. Treatment. — Dr. Hardy has never bled in this fever, and rarely 
cupped. He has not vomited and but seldom purged. His reliance has 
been on a combination of calomel, ipecac, and opium, with cold affusions or 
spongings. A salivation has seldom occurred. To check the diarrhoea he 
has added sugar of lead to the other remedies. He has given James's 
powder and other sudorifics a full trial, but was disappointed. He has 
oftener seen a perspiration follow the cold bath. Subacid drinks have been 
useful. He thinks blisters of less value than sinapisms. He has covered 
the abdomen with a mush poultice sprinkled with powdered mustard, and 
it greatly mitigated the abdominal symptoms. He has used but little sul- 
phate of quinine ; and when a tonic was required gave a cold infusion of 
wild cherry bark, Prunus Virginiana. 



INTERIOR VALLEY OF NORTH AMERICA. 377 

SECTION V. 



I. This region lies near and immediately north of the one just described, 
but at a lower level. It gives us the descent or transition from the moun- 
tain valleys to those of the great plain which stretches off -to the Mississippi 
River. The study of its fevers is on that account the more interesting. 
Its higher counties are Sullivan, Carter, and Washington. Its most important 
town Jonesboro. I have not been able to visit this district, and shall avail 
myself of the published observations of Dr. Cunningham, a very competent 
physician, of Jonesboro. 

II. History. — In a report on the fevers of East Tennessee that gentleman 
has, in a general way, indicated the prevalence of typhous fevers in this 
region. They prevail on dry ridges, while remittents and intermittents 
occur along the streams, with now and then a case in both localities at 
once periodical and typhous. They prevail through all the seasons, and 
often occur in what are apparently the most healthy localities. The follow- 
ing summary of symptoms is extracted from his paper. f 

" For upwards of twenty years, we have had frequent opportunities of 
meeting with it, and observing its phases. Patients generally complain 
for days, or sometimes for weeks, before the attack, of loss of appetite, head- 
ache, listlessness and dulness. Sometimes these symptoms steal on gradu- 
ally, until the patient goes to bed without any marked chill or fever, or 
much increase of pulse, or other symptoms which attend the stadium pro- 
dromorum of the other fevers. There is merely an increased indisposition 
gradually developed, some excitement of pulse, the secretions failing almost 
unobserved, so that it is difficult to fix any precise period of accession. The 
appetite and other functions seem to fail pa ri passu with the gradual incre- 
ment of fever. When these premonitory symptoms are early attended to, 
the danger is pretty easily averted. A purge or two of calomel and oil, 
with light diet and rest; or a few powders, daily, of ipecac, and calomel, 
restore the functions. But when neglected until fever is fully developed 
the issue is often serious. During the progress there is accelerated pulse 
from day to day, with very little diurnal remission ; towards morning there 
is generally an alleviation, but not a marked remission of symptoms. The 
pulse may diminish its number some five or ten beats per minute. Pains in 
the head and back (especially the latter, which never fails to be present), 
are for some days all that is complained of. The heat is but slightly in- 
creased, and the sudorous discharge diminished but little. The tongue, too, 
alters but slowly : at first clammy, then white, next brown or black, then 
all secretion fcr a time suspended, and nothing but a fiery redness in the 
middle, and as clean as if scalded and scraped, — dry, chapped and tremulous. 

* See vol. i. p. 227-9, No. XIII. t Eve's South Med. and Surg. Jour, for July, 1847. 



378 THE PRINCIPAL DISEASES OP THE 

Then follow colliquative stools, incoherence of thought, and without a 
change, the patient is lost." 

** ###*## 

" Abdominal tenderness on pressure, rarely present at the beginning, is a 
pretty constant symptom after it has advanced but a few days ; and it is one 
of the most difficult to meet of all the attendant symptoms." 

III. Treatment. — In the forming stage of this disease Dr. C. has seen 
one or two doses of calomel and oil, with light diet and rest, or a few 
powders daily of ipecac, and calomel, restore the functions. In the course 
of the fever he lays great stress on cupping over the spine, and the subse- 
quent applications of rubefacients to that part and also to the feet and legs. 
He found active purges injurious — the pulse becoming more frequent and 
the abdominal tenderness greater, under their use. He administered de- 
mulcent drinks freely, and often combined opium with ipecac, and calomel, 
with good effect. Blisters also proved serviceable. A mild mercurial 
action was auspicious. Sulphate of quinine was tried, but except in remit- 
ting cases did no good — perhaps harm. On the whole he concluded that 
in general nothing could be effected but to correct particular symptoms, 
and await the spontaneous issue of the disease. 

In the winter season many cases were complicated with inflammation of 
the lungs, when early bloodletting was indispensable. 



CHAPTER III. 

LOCAL HISTORIES OF TYPHOUS FEVERS IN THE SOUTHERN BASIN, CON- 
TINUED; IN PENNSYLVANIA, OHIO, INDIANA, AND ILLINOIS. 



SECTION I. 

IN AND AROUND UNIONTOWN, PENNSYLVANIA.* 

I. An epidemic began in the summer of 1846 and continued through the 
winter and following spring, not having entirely ceased when I visited the 
place in July, 1847. According to Dr. Fuller and Dr. Walker, my principal 
informants, this fever prevailed in a high valley east of Laurel Mountain, before 
it appeared in Uniontown, which stands at the western base of that mountain. 
The first two cases of which they knew anything were in a poor family, seven 
miles out of town. Ten or twelve families lived near, in a kind of hamlet, 
and every family which had intercourse with those two patients suffered from 
the fever. Two brothers came from the country to see a sister sick with the 
fever in Uniontown, and both were attacked after returning home. Dr. 

* See vol. i. p. 268. 



INTERIOR VALLEY OF NORTH AMERICA. 379 

"Walker knew of four other cases of the same kind. The chief subjects 
were men. Saw no children under the eighth year attacked by it. In the 
county almshouse, three miles out of town, there were twenty-five cases 
among eighty inmates. It oftener proved fatal in a fortnight than at any 
other time, and those who got well, generally began to mend at the end of 
three weeks. Very protracted cases generally ended in recovery. . 

II. The access of the fever was marked by the usual chilliness and lan- 
guor. Diarrhoea was an early symptom, and the discharges often thin and 
yellowish, were followed by a tendency to syncope. Not one patient was 
costive. The worst cases were attended with irritability of the stomach and 
vomiting. Abdominal pain, especially in the right iliac region, was com- 
mon. The tongue in the beginning was covered with a yellowish fur, which 
soon dried, changed to brown, and the organ contracted laterally, with a red 
tip. Sordes on the teeth were common. Stupor, delirium, and subsultus, 
in many patients, were of early occurrence. The eyes put on a yellowish, 
bloodshot appearance. A flea-bite efflorescence appeared in a large propor- 
tion of cases ; in a few on the arms and legs, but generally limited to the 
forepart of the trunk of the body. They commonly appeared on the third 
or fourth day after the reaction commenced, and disappeared before the 
end of the disease. In some protracted cases, accompanied by perspiration, 
sudamina occurred. One-fourth of all his patients had intestinal hemor- 
rhage, which in the early stages seemed beneficial, but in the latter injurious 
and portentous ; indeed all his fatal cases were attended with hemorrhages 
in their latter stages. A boy fourteen years old, who had experienced an 
attack of purpura hemorrhagica four years previously, had bleeding from 
the nose, mouth, and kidneys. Coldness of the knees while the feet kept 
warm portended a fatal termination. In the course of several bad cases, 
bronchitis supervened. 

III. Dr. Fuller made a post-mortem inspection of those who died in the 
almshouse. In the stomach of one he found ulceration ; in another the 
ordinary ravages of gastritis ) in the remainder no signs of inflammation. 
In all he met with diffused inflammatory redness of the mucous membrane 
of both the ileum and colon, interspersed with ulcers, affecting chiefly the 
elliptical patches : portions of the ileum were, in some, greatly contracted. 
There was no perforation of the bowel. The spleen was generally sound, but 
in one subject enlarged, and almost as pulpy and tender as a coagulum of 
blood. Two brains were examined, one of which was healthy, the other 
was in a state of hyperaemia, and the ventricles contained a quantity of bloody 
serum. My notes do not embrace anything else. 

IV. In the treatment of this epidemic Dr. Fuller bled about one-half his 
patients, and thought they did better than those which were not bled. He 
commonly drew sixteen ounces, and seldom repeated the operation. The 
blood was in some cases sizy, in others not. He cupped in every case, 
generally drawing from six to eight ounces \ this operation was in many 



380 THE PRINCIPAL DISEASES OF THE 

patients repeated several times and seemed to do much good. He saw a 
blister to the abdomen arrest the diarrhoea. Warm and even hot fomenta- 
tions to the same part relieved the pain and tenderness and often brought 
on perspiration. In several instances, the people seemed to " break the 
fever" in its early stages by surrounding the patient with ears of Indian 
corn boiled and applied hot, sweating teas being at the same time adminis- 
tered freely. Vomits were not used, and but little calomel. Active purg- 
ing was injurious. The hydrargyrum cum creta was found useful, especially 
when combined with the ipecac, and sulphate of morphia, After the diar- 
rhoea was arrested, he sometimes gave teaspoonful doses of castor oil. 
The most manageable cases were those of greatest arterial reaction, with but 
little gastric irritability. A copious bloodletting followed by Dover's pow- 
ders, frequently arrested them. In the advanced stage of the several cases 
the sphincter ani seemed paralysed, for the patients would have involuntary 
evacuations, of which they were fully conscious. He administered brandy 
and carbonate of ammonia in a few cases, but the results were bad. In pro- 
tracted cases, beef tea was found useful. Dr. Walker's practice was substan- 
tially the same as Dr. Fuller's. 

Y. At the same time that this fever was epidemic at Uniontown, it pre- 
vailed at Brownsville, twelve miles from the mountains.* Prevailing more 
or less" in the summer, it reached its epidemic acme about the middle of 
winter. Dr. Lafferty met with no facts showing a contagious character, and 
saw many patients who had not been near those laboring under the disease. 
It prevailed chiefly in town, and the country cases were mildest. Diarrhoea 
was present in every case, and often constituted the first symptom. It some- 
times continued for two weeks before the patient took to his bed. In some 
cases the appetite was unimpaired throughout the -whole course of the dis- 
ease. In several he observed rose-colored maculre on the trunk of the body. 
It is unnecessary to recount all the symptoms, as they were nearly the same 
with those already described. About one-tenth of those who were so ill as 
to lie in bed, died. Dr. Lafferty's treatment was nearly the same as that which 
has been given, but he did not bleed. Two-grain doses of acetate of lead, and 
twenty-drop doses of oil of turpentine, were found useful in the diarrhoea. 
He tried sulphate of quinine, and found it injurious. 

Of the different epidemics which have been described this manifestly ap- 
proaches nearest to the " typhoid affection" of Louis. 



SECTION II. 

IN WASHINGTON AND THE SURROUNDING COUNTRY.f 

I. Dr. Lemoine assured me that for fifteen years before 1847, the fevers of 
this region had been assuming more and more of a continued and typhous 

* See vol. i. p. 268-9, No. VIII. f Jbid. 



INTERIOR VALLEY OF NORTH AMERICA. 381 

character. In latter years single families or limited neighborhoods will be 
invaded by a continued fever. It occurs oftenest between October and April 
inclusive. The pulse is apt to be exceedingly frequent. Diarrhoea is com- 
mon, intestinal hemorrhage not rare. Rose-colored spots are often seen on 
the abdomen and petechias on the extremities. Patients often die at the 
end of two weeks, or recover in three, four, or five. His treatment was in 
no respect peculiar. 

II. In the town of Washington, during the winter of 1846-7, about thirty 
cases occurred. In one dirty and crowded house there were, according to 
Dr. Wishart and Dr. King, six cases, three of which proved fatal. In 
another house, better kept, out of six college students, four had the fever. 
The duration of the attack was generally about three weeks. There was no 
evidence of contagious propagation. One patient was bled and recovered. 
The blood was not buffy. An emetic in the beginning put an end to the 
protracted chilliness. Subsequently the saline mixture (solution of acetate 
of potash with a minute addition of tartarizsd antimony) was found useful. 
Epigastric cupping, followed by cataplasms of Indian corn meal and pow- 
dered mustard, was found serviceable. 

III. From Dr. Keed, I obtained the following facts : Taylorstown, in a 
valley not far from Washington, had a population of about 120 souls. In 
1839, one of its inhabitants, on his way home from some place in the moun- 
tains, was attacked with continued fever, of which he died in a week after 
reaching home. His father and two sisters sickened with the same fever. 
A friend who came to nurse them experienced the same fate, as did two of 
his children. A woman who visited the first family experienced an attack, 
and progressing through the winter, eight out of nine children were taken 
down. Out of the 120 inhabitants of the village, fifty suffered from the 
disease and eight died. When I was at Washington eight years after this 
visitation, no other had been experienced. Dr. Davidson has informed me, 
that he attended many of the patients in this little epidemic, which seemed 
to spread from the family in which it first appeared. Diarrhoea was replaced 
with costiveness, so that aperients were necessary. The stomach was gene- 
rally tranquil. A few patients had hemorrhage from the bowels. The dry 
and red appearance of the tongue, and the delirium, stupor, and subsultus of 
the latter stages, marked it as a typhus fever. He bled most of his patients 
once, some of them two and three times. The blood was often sizy. He 
found no medicine capable of arresting the fever, and after the first cases, 
waited for a spontaneous termination. 

IV. In the winters of 1834-5 and 1835-6, Dr. Grafton, resident at Wells- 
burg on the Ohio, but practising in the same region with Dr. Davidson, 
encountered a typhus fever, which was most prevalent in the second of 
those winters, when it made its way into the village. 

It commenced in autumn and continued through the winter. Its general 
symptoms were those of the typhus mitior of the systematic writers ; coma ; 



382 THE PRINCIPAL DISEASES OF THE 

delirium, and subsultus tendinum, being among its phenomena. Diarrhoea 
chiefly occurred as a consequence of purging. In its treatment Dr. G-. was 
cautious about the exhibition of cathartics ; and used opiates and demulcents. 
Externally he resorted to cupping, blisters, and sinapisms. This gentle 
treatment was uniformly successful. Dr. Gr. understood that venesection 
and liberal doses of calomel were employed without success. 



SECTION III. 

IN AND AROUND PITTSBURG.* 

I. In 1847, Dr. G-azzam, long resident in this city, assured me that 
typhus fevers, for several years past, had occurred more frequently than 
formerly, yet the place had not been seriously visited. Only now and then 
had the fever approached to an epidemic character. According to Dr. Bruce 
an invasion of this kind occurred in 1846. Diarrhoea was generally present, 
often at the beginning, but sometimes not till after the second week. 
Tenderness with meteorism and gurgling in the right iliac region was com- 
mon. Intestinal hemorrhage was common. In one case after continuing 
for twenty-four hours, it seemed to be arrested by oil of turpentine. Nearly 
every patient was delirious. It attacked males and females equally, gene- 
rally seizing those in the first half of adult life. The earliest convalescence 
which he witnessed was on the 18th day. It often ran through five weeks. 
Bloodletting was not beneficial. No prescriptions had the effect of shorten- 
ing the fever. 

II. For three years Dr. Hamilton witnessed a considerable prevalence of 
the same kind of fever in the city of Allegheny adjoining Pittsburg. Chil- 
dren under ten years of age were exempt. The bowels were so irritable 
that only the mildest aperients could be borne. Congestions of the brain 
and lungs were common. Local bleeding was beneficial. In some cases he 
found the sulphate of quinine useful. Dr. Smith of the same city saw cases 
of the fever which continued for three months. Many patients kept in bed 
for six weeks. It often attacked vigorous and hard-working young men. 
In some cases the mouth became aphthous. He bled in a few cases only, 
but cupped with advantage. The diarrhoea was often checked by small 
doses of turpentine. The fever could be moderated by powders of nitrate 
of potash, calomel, and ipecac. Small doses of sulphate of quinine were 
sometimes useful. Opium generally increased the cerebral symptoms, and 
both he and Dr. Hamilton found the extract of hyoscyamus preferable. 

III. At Butler.")" Dr. De Wolfe had resided in this town thirty years 
when I passed through it in 1847. For the first seven years the febrile 
diseases were decidedly inflammatory, showing no typhous tendency. In the 
year 1823, a man returned from the Ohio River, with a fever of the latter 
kind. In the course of a year Dr. De Wolfe had more than 100 cases of 

* See vol. i. p. 271, No. I. f See vol. i. p. 276, No. II. 



INTERIOR VALLEY OF NORTH AMERICA. 383 

the same character, all of which, according to his observations, could be 
traced directly or indirectly to this case. The duration of the fever in 
different cases continued from four to ten weeks. It spread but little into 
the surrounding country. For eight or ten years after the onset of this 
local semi-epidemic, the diseases of that place manifested more or less of a 
typhous character. 

SECTION IV. 

IN TRUMBULL,* AND THE ADJOINING COUNTIES. 

I. According to Prof. Kirtland, the epidemic typhous constitution of 
1813, described in Section II., continued with more or less intensity, in cer- 
tain parts of this county, for the ensuing twelve or fourteen years. Early 
in the summer of 1827, " a low malignant typhus/' began to manifest itself. 
The succeeding winter is reported by Dr. Allenf to have been unusually 
warm and wet. In the following summer it returned with greater violence, 
beginning with July and terminating with November; during which, 
although it was at first confined to a large family connection, it overspread 
a parallelogram of ten by twenty miles. In the summer of 1829 it 
appeared in a distinct neighborhood, again prevailing first in a single family, 
and spread over a tract of country almost as great as before, after which it 
disappeared. 

II. The following is Prof. Kirtland's summary of the symptoms cf this 
epidemic, which he denominates typhus syncopalis : — 

" Persons of all ages and both sexes are equally liable to its attacks. The 
prominent symptoms are, pains in the head, back, and limbs, oppression 
about the eyes and forehead, cold extremities for some days before the true 
character of the complaint is fully developed, unequal excitement, nausea, 
and vomiting, torpor or irritability of the stomach and system generally, the 
appearance of the tongue varying at different times in the same patient, 
and affording little information as to the state of disease, the face livid and 
strongly marked with the Hippocratic features, even from the first moment 
of the attack, the skin either moist, cold and clammy, shrivelled and dry, 
or painfully hot to the touch, from the calor mordax or stinging heat, when 
perhaps the actual temperature of the sick is below that of ourselves; sanious 
hemorrhages, petechia, subsidensia, coma, and delirium. 

" The several varieties of this fever are formed by different combinations 
of a greater or less number of these symptoms, yet no one of them can be 
considered as common to every case, unless it be the gastric sinking ; a ten- 
dency to which is not often absent. It is a deathlike sensation referred to 
the epigastric region, and occurs in paroxysms, attended with cold extre- 
mities, vertigo, feeble pulse, palpitation of the heart, difficult breathing, 

* For some general notices of the medical topography of the region which includes these counties, 
see vol. i. p. 282-6. 
t MS. letter. 



384 THE PRINCIPAL DISEASES OF THE 

spasms, and a livid, distressed countenance, and is liable to occur daily at 
regular periods, or may be produced by raising the patient from a horizontal 
posture. The light attacks are often mistaken by nurses and bystanders for 
faintings."* 

From Dr. Allen's letter, I collect that the pulse in some cases showed in- 
creased energy, but was generally frequent, small, and soft. The bowels 
were easily moved, though sometimes costive. In the latter stage of the 
fever, many had alvine discharges of blood. No post-mortem examination 
seems to have been made. 

III. Methods of Treatment. — Professor Kirtland refers the treat- 
ment in the epidemic to two heads, counteraction and support, observing that 
in some cases it was necessary to transpose their order, and sustain the sink- 
ing energies of the system before employing counter-irritants ; adding as a 
general remark, that whatever tended to reduce or exhaust the patient, had 
to be avoided. Bloodletting, purging with neutral salts, and emetics, espe- 
cially of tartarized antimony, were found injurious. Calomel and magnesia, 
to produce moderate alvine evacuation, he found serviceable. Nauseants, 
nitre, saline effervescing draughts, vegetable acids, sweet spirit of nitre, and 
cold drinks, he found either inert, or positively injurious. His internal 
corroborants were brandy, wine, capsicum, tincture of cantharides, carbonate 
of ammonia, camphor, serpentaria, cinchona, quassia, but above all opium, 
to which he added arsenic, when a case displayed something of an intermit- 
tent character. He also administered soup, coffee, and other nutriments. 
Externally, he applied the warm bath, quenched fire-brands, blocks of wood 
steeped in boiling water, and large blisters renewed daily, to the limbs, head, 
and nucha; sinapisms, and bandages dipped in hot oil of turpentine. His 
method, in short, was that of active and unabating stimulation — internal and 
external. Professor K. does not tell us what proportion of the sick re- 
covered under his treatment. 

The method pursued by Dr. Allen was substantially the same. After 
enumerating its items in detail, he observes : " The doctrine we were taught 
in our youth, that the debility in fevers is indirect or consequent on previous 
excitement, did not hold good in this epidemic. " 

"I recollect," continues he, " more than once of entering the room of a 
distant patient bathed in cold perspiration under the use of nitre, Dover's 
powder, &c, who was immediately relieved and restored by brandy and qui- 
nine." "In 1829," he adds, " the epidemic commenced about twenty miles 
from my residence, and the first patients, together with the physician who 
attended them, died. On visiting the neighborhood, I advised another phy- 
sician, Dr. Palmer, to pursue the course I have recommended, which he did, 
and of between twenty or thirty cases all recovered except one, who was lost 
by relapsing. " 

Columbiana County. — I am indebted to Dr. George M'Cook, of New 
Lisbon, in this county, for the following brief notice. In the winter of 1822-3, 

* Medical Recorder, yol. xiv. p. 441. (Ed.) 



INTERIOR VALLEY OF NORTH AMERICA. 385 

a typhus fever broke out four miles from town, in a family which had 
lately emigrated from New England, where a fever, which they declared to 
be of the same kind, prevailed. Three out of four of the family died of it. 
The fever soon extended over the country ; but no facts are given to show 
that it spread from this family. It affected the people living on elevated 
places, more than others. The duration of the epidemic constitution was 
about four years, after which up to 1846, it had not returned, except spo- 
radically. The cases in which the onset of the fever was not sudden and 
violent, proved most amenable to treatment. In the worst cases, the heat 
of the surface was defective. An intolerable pain in the front part of the 
head was a common symptom. Deafness occurred in three cases, all of which 
proved fatal. In some, the hearing was morbidly acute. Delirium, coma, 
and subsultus tendinum were common. Several patients had hemorrhage 
from the nose, a greater number from the bowels, and both were bad symp- 
toms. Of the state of the bowels, Dr. M'C. does not speak, but mentions 
abdominal tenderness. For the cure of this fever, he first administered 
tartar emetic and calomel, so as to vomit and purge. In many cases he re- 
peated the emetic. Afterwards he sought to re-excite the functions of the 
skin with stimulating diaphoretics, such as an infusion of aristolochia serpen- 
taria, with camphor, opium, and carbonate of ammonia. To a patient 
affected with extreme jactitation and subsultus tendinum, so that death 
seemed to be at hand, he gave " incredible doses" of opium and camphor, 
and applied sinapisms to the wrists and ankles, under which, recovery took 
place. 

This epidemic constitution continued about four years, and when Dr. M'C. 
wrote in 1846, it had never returned ; but occasional cases of a typhous 
character were seen. 



SECTION V. 

IN BELMONT AND THE ADJOINING COUNTIES.* 

I. History. — Dr. Thomas Carroll, now of Cincinnati, but formerly of 
St. Clairsville, in Belmont County, has published an account of a typhus 
fever which occurred in his practice."!" He first met with it in 1826, but it 
might have prevailed before, as he was not there. For the next sixteen 
years he often met with it ; sometimes in one part of the country, at other 
times in other parts, and also in the adjoining counties of Harrison and Jeffer- 
son. In the year just mentioned, it commenced late in autumn, and he saw 
more than fifty cases of it. In other years, and oftener than otherwise, it began 
in the winter. It generally commenced with a single individual of a family 
in the country, in a week or two after which another would be seized, and 
then another. Meanwhile some one or more of the neighbors who visited 

* See yol. i. p. 282-6. t Western Journal (Louisville), yol. v. p. 31. 

vol. ii. 25 



386 THE PRINCIPAL DISEASES OP THE 

the family would be taken down, and then some member of a third family, 
who had visited the sick in the second. Thus, it seemed to spread by con- 
tagion. In that county there are many families of the Society of Friends 
(Quakers), noted for their temperate habits, domestic cleanliness and com- 
fort, not less than their humane and diligent attendance on the sick; among 
whom he observed the fever to be peculiarly prevalent. Children as well 
as adults were obnoxious to it; and no mode of living seemed either to 
invite or repel its attacks. 

II. Symptoms. — I shall borrow Dr. Carroll's condensed account of the 
symptoms which characterized this fever : — 

" When an individual is about being taken with this fever he appears 
languid, has a bad appetite, and complains sometimes of a headache, and 
again of pain in the back ; inclines to sleep, though his slumbers are dis- 
turbed, and he rises from them without feeling refreshed. After some days 
spent in this way, he gets out of bed but seldom, eats little or none, and his 
mind sometimes wanders when he is aroused. In a day or two more he lies 
all the time, unless his brain be seriously affected, when he is often much 
inclined to sit up, even when very ill. If his skin be examined during this 
time it will be found dry and inactive, and when pinched into folds it regains 
its smoothness very slowly, showing the loss of its elasticity. There is com- 
monly but little flushing of the face at the commencement of the disease, 
but, as the fever advances, this symptom becomes more developed, especially 
in the after part of the day, and in some cases is eventually relieved by 
sweating. If the brain be diseased early, he will often show slight deli- 
rium, and will mostly complain of disagreeable feelings when he shakes his 
head, which he will not do without being urged ; the eyes frequently become 
more brilliant than usual, and there is sometimes morbid acuteness of vision, 
with suffusion of the conjunctiva. Headache is not always present when 
the brain or its membranes are affected, and it is often present when the 
result shows that these parts were very little, if at all, inflamed. When the 
patient gets down it will be found that the fever is regularly augmented in 
the afternoon, and during the fore part of the night, when it begins to 
become more mild and abates considerably against morning ; but is again 
renewed with the same result as before. It, however, is commonly more 
severe every other day throughout the course. During the continuance of 
the fever, the surface is generally somewhat above the natural temperature, 
though it is often not warmer than in health, and frequently as cool or even 
cooler. Sometimes this fever appears in an acute form, running its course 
in a few days. In these cases, the brain or heart is most deeply affected, 
sometimes one of these organs being more diseased and sometimes the other. 
When the heart is affected, the pulse has an irregular beat, and seems 
corded, and occasionally intermits ; but when the brain is affected there are 
delirium, pain in the head, with subsultus, intolerance of light, &c. The 
acute form is sometimes occasionally ushered in with chills. This symptom 



INTERIOR VALLEY OF NORTH AMERICA. 387 

is, however, seldom observed at the commencement of the subacute. A dry 
tongue is very common at all periods, but especially in the latter, when it is 
often brown in the centre, with a flabby inactive appearance. When the 
patient attempts to put it out, it seems to catch on the teeth. It is some- 
times pointed. The former of these symptoms is unfavorable, the latter 
more so. 

" It is, probably, unnecessary to say anything now about the symptoms 
which mark a favorable termination of the fever. I will, however, make 
a few remarks on those that are unfavorable. Great irritability of the 
stomach with pain in it and the bowels, and tenderness of the epigastrium 
and abdomen generally, are unfavorable ; hemorrhage from the bowels is 
among the most unfavorable symptoms ; and still more so is a swelling of 
the penis ; indeed I have but seldom seen a recovery from fever when this 
symptom supervenes. The want of the tonic contraction of the cremaster 
muscles is also unfavorable ; when this is the case, the testes are found low 
in the scrotum, which is also relaxed. I am inclined to think that when 
these two last symptoms are present, the brain is incurably affected. It 
might be improper for me to pass over another symptom that I have often 
witnessed. When you lift one of the forearms, so that it forms with the 
arm a right angle, and hold it there a few moments, and then take your 
hand away, if it be retained by the patient in this position, voluntarily, 
until it begins to tremble, and then falls without a voluntary act of the 
patient, it may be considered that danger is present and the chances of 
recovery are few." 

III. Treatment. — The duration of the fever varied from one to seven 
weeks, or even more. After it was established, no course of treatment 
seemed to shorten it; and any great reduction of the vital forces for the 
purpose of producing that result did harm. According to Dr. Carroll : 

" The first step to be taken in the acute form of this fever, is to bleed 
until the patient either approaches to syncope or does faint j to effect this 
without danger, he should be in a sitting or erect position when bled. As 
soon as he partially recovers from the effects of the loss of blood, he should 
be placed in a sitting position, when two or three gallons of cold water 
ought to be dashed over him ; if his head be much affected it should be 
allowed to fall in a heavy stream on it, for by this means it will be much 
relieved. It then becomes necessary to administer either a cathartic or an 
emetic. If the patient have a foul tongue and his head be not much affected, 
the latter should be preferred ,* but if these circumstances do not exist, the 
former should be chosen. Should the physician determine in favor of an 
emetic he will consult the interests of his patient by giving him, in some 
warm water, half a grain of tartar emetic, and one or two grains of ipeca- 
cuanha combined, every half hour, until vomiting is effected. It is now 
important that a powerful cathartic should be given, composed in most 
cases, of calomel and jalap, or for the jalap, castor oil, or senna and salts, 



388 THE PRINCIPAL DISEASES OF THE 

or, in weak constitutions, rhubarb. After a free cathartic effect has been 
obtained, tartar emetic should be given in such doses as will not sicken, and 
be persevered in throughout the disease, unless it should be found that it 
does not agree with the patient. But few cases will be met with, however, 
where a twelfth of a grain cannot be borne, and this amount will be suffi- 
cient to begin with, and should it be borne with ease, the dose can be in- 
creased as occasion may require. It should be given every four or six 
hours. After a free cathartic influence has been obtained, twenty grains 
of calomel should also be given and repeated every six or eight hours, until 
the mouth becomes sore, or the specific effect is produced on the general 
system ; for many cases will be met with where the mouth cannot be made 
sore, yet the constitutional influence of the mercury will be obtained. 
When the calomel has been given until it has produced its specific effect, 
no more should afterwards be exhibited than enough to keep the secretions 
of the alimentary canal right. Two or three grains a day will be found 
sufficient for this purpose, and if profuse salivation should occur, no more 
should be given for at least a week. It has been a favorite opinion with 
many, that when salivation is once produced, the fever of course ceases. 
This opinion is, however, fallacious, for nothing is more common than to 
see the fever go on for weeks after the specific influence of mercury has been 
induced. It is true that it is generally mitigated by the mercurial action, 
but by no means always destroyed. 

"When the disease commences in a slow manner, the patient not even 
complaining of chilliness, it may be called subacute, and must be treated 
more mildly. If there be no tenderness of the epigastrium, and if the 
brain be not affected, the treatment may be commenced with an emetic, after 
which a dose of calomel and jalap, or rhubarb, should be administered, and 
repeated every few hours until it operates. So soon as the bowels are 
cleared, antimonials should be given, and continued as directed above. Five 
grains of calomel, or more, should be given every four or six hours, until 
the mouth is made slightly sore, or the general system is affected, which 
will be known by an increased fulness and regularity of the pulse. When 
this is brought about, all has been done that can be advantageously accom- 
plished by mercury in large doses. As in acute cases, the action of the liver 
and the secretions and excretions of the abdominal viscera generally, should 
be kept in a proper state of activity. This can be best done by calomel or 
the blue pill. I am much in favor of the latter in female patients, and in 
all delicate or enfeebled constitutions. One or two alvine evacuations should 
be procured daily through the fore or middle part of the fever; but if it 
continue for a long time, as for more than two weeks, I would only wish one 
evacuation a clay, or one every other, or every third day, if the patient 
should be very low. Rhubarb, combined with compound extract of colo- 
cynth, and a small proportion of ipecacuanha, will form a very good combi- 



INTERIOR VALLEY OF NORTH AMERICA. 389 

nation for the purpose ; the physician will, however, find jalap, salts and 
senna, and magnesia, to answer a good purpose. 

"When there is local inflammation or congestion of the brain, or of any- 
other part of the system, whether in the acute or subacute forms of the 
disease, attention must be given to it. If in the brain or its membranes, 
keeping the hair wet with cold or tepid water, will be of use. Cupping on 
the temples or back of the neck, will also be of much service. Should those 
not relieve, I would advise blistering on the head or neck. When there is 
pain in the small of the back, cupping and blistering will be of much ser- 
vice. If the stomach be irritable, or if there be tenderness of the epigas- 
trium, cupping should be used, and after it, blistering. If the patient be 
weak, it would be better not to scarify. If there be pain or tenderness gene- 
rally diffused over the abdomen, cupping should never be neglected. Half 
a dozen cups, either with or without scarification, will give great relief, and 
this may be repeated several times, if the irritability continue. Local ap- 
plications may be used with advantage. 

"It is a matter of moment in the treatment of this fever, that nothing 
shall be done to bring the pulse below the natural standard for any length 
of time. I would always prefer having a pulse a little above this standard. 
When it falls below, means should be taken to raise it. This is effected by 
the addition of camphor, ammonia, good wine, or brandy. Opium will often 
be found useful, particularly when combined with ipecacuanha, but I think 
five-grain doses of camphor, with a grain of ipecacuanha, if the latter be 
admissible, will answer a better purpose than most other stimulants. Sul- 
phate of morphia or opium may be added, if thought proper. If these 
three medicines be given in combination, when there is a disposition to sweat, 
their effects will be most salutary. I should not neglect to observe, that 
sulphate of quinine, if given in moderate doses, is a medicine of great value 
in the treatment of this fever, when much debility is present. 

" Much has been said for and against bleeding in the cure of this fever, 
and it has been urged that physicians who have been in the habit of bleed- 
ing for it, have often been unfortunate j this I cannot deny. Bleeding is 
but seldom necessary, as the warm or cold affusion will generally moderate 
the force of the fever more safely than bleeding ; indeed, I would advise the 
young practitioner to resort to the lancet with much caution, for if he bleeds 
s<5 that the pulse does not regain a firm beat, he will assuredly lose his 
patient. 

" Sometimes after this fever has existed for a number of days, or even 
weeks, hemorrhage from the bowels takes place. This may be feared when 
the tongue of a sudden loses a thick coat, which comes off in flakes, and 
leaves the surface smooth and red, with a polished appearance, and in cases 
where but little emaciation has taken place, and where there is fulness of 
the abdomen. The most common cause of its appearance is excessive pur- 
gation, for a number of days. This is particularly the case where calomel 



390 THE PRINCIPAL DISEASES OF THE 

has been given in large quantities at the same time that cold water has been 
administered largely. Some practitioners never give up the administration 
of calomel in frightful doses until their patients are either salivated or poi- 
soned to death. Uninterrupted purging is wrong, and giving mercury with 
an idea that it does no good unless the patient is salivated, is as bad. This 
most potent medicine is shamefully abused in this way, and I am not certain 
but that its indiscriminate exhibition with cold drinks, often has a nrost in- 
jurious tendency. When hemorrhage occurs, it becomes necessary at once 
to cease giving the purgative medicine, and to give opiates every six or 
eight hours, until the bleeding ceases. The addition of ipecacuanha to the 
opium will be useful, and if but little mercury has been administered, mode- 
rate quantities* of calomel should be combined with the opium or morphine. 
Dry cupping will be important over the abdomen, after which a blister 
should be applied. Purging must not be attempted under four or five days, 
when rhubarb or castor oil should be given slowly until the operation is 
procured. When this is effected, great care should be taken to avoid fre- 
quent purging. Quinine is often of much use after great loss of blood in 
this way ; wine and brandy are also useful. The first cases of this affection 
which I saw all terminated unfavorably • indeed, I at one time almost came 
to the conclusion that death was inevitable, but, eventually, being called to 
a case in my own practice, where the family had given large doses of salts, 
I concluded that I would try calomel, opium, and ipecacuanha, and I had 
the satisfaction of saving my patient, and have not lost one since with 
bleeding from the bowels. I did not suffer the patient in this case to take 
any cathartic medicine for more than a week. However, in about five days 
he had an operation from the effects of the calomel. When I first saw this 
patient, I thought all was over with him, as I found him in a fainting con- 
dition from the loss of blood. Since the time I attended this case, I have 
seen several nearly as bad, and some much worse, yet they all recovered. 

"In conclusion, I may observe, that if the method which I have laid 
down for the treatment of this fever be pursued, but few cases will be lost. 
During a residence as a practitioner of medicine in this district of country, 
which I have described, for eighteen years, I lost but very few cases, pro- 
bably not more than one in each year, and indeed I shall always look back 
with pleasure upon my success in the treatment of these cases/' 



SECTION VI. 

IN GREENE COUNTY, OHIO. 

I. The surface of this county is substantially the same as that of Fay- 
ette.* Dr. Dawsonf has published an account of 21 cases of typhus fever 

* See vol. i. p. 294, No. II. t West. Jour. (Louisville) for Sept. 1SU. 



INTERIOR VALLEY OF NORTH AMERICA. 391 

which had lately occurred in his practice, which considering the sparseness 
of population in and around the village of Jamestown, in which he resides, 
are sufficient to constitute it a minor epidemic. I gather from his papers 
the following facts : — 

1. For 6 or 8 years he had observed, every winter, several cases of con- 
tinued fever which he regarded as of a typhous character ; but a short time 
before he wrote, July 1st, 1844, 21 cases had occurred in his practice. 

2. Of these cases 19 were in persons of middle age, one in an individual 
60 years old, and another in one of fifteen. Sixteen of the patients were 
males and- five females. 

3. Five of the cases could not be traced up to any communication with 
the sick ; but 16 had been exposed to the atmosphere of the disease. 

4. Stupor, more or less profound, was present in every case ; being slight 
in the beginning and gradually increasing to the decline of the fever, when 
in several instances it was apparently carried off by a critical evacuation, in 
which cases the recovery of mental activity was always quick. 

In one case the coma for three weeks was so unabated, that the patient, 
a female, was unconscious of everything that passed. In nine cases delirium 
was combined with coma. 

5. In 13 cases, or about two-thirds of the whole, diarrhoea prevailed with 
more or less severity. It was characterized by dark watery discharges, oc- 
casionally greenish, which sometimes contained what appeared to be shreds 
of mucous membrane. The occurrence of this diarrhoea marked a violent 
disease. Under its prevalence there was rapid prostration of strength ; the 
pulse became frequent and feeble, the tongue red and dry, and the thirst 
intense. A few of these cases were attended with epigastric tenderness, 
pain, and meteorism.. 

6. Hemorrhage from the bowels occurred in two cases; on the 14th and 
21st days of the disease. In one the quantity discharged was only half a 
pint, in the other half a gallon. Both patients recovered. 

7. Two cases were complicated with pneumonia, which in one supervened 
on the 24th day, in the other in the second stage of the fever. Both 
patients were cured, though the former was ill for several weeks. 

8. In two patients there was a retention of urine which required the use 
of the catheter, and in a majority there was more or less distress in micturi- 
tion. 

9. The fever in its times of termination seemed to observe hebdomadal 
periods, terminating on the seventh, fourteenth, twenty-first, or twenty- 
eighth day ; but when it became complicated with a local inflammation it 
lost this character. 

10. In the treatment of this epidemic Dr. Dawson did not find bloodlet- 
ting an available or valuable remedy. In the forming stage an emetic 
sometimes broke up the fever, and subsequently tartar emetic, as a con- 
tra-stimulant, moderated the febrile excitement. A mercurial action except 



392 THE PRINCIPAL DISEASES OF THE 

in the very commencement of the fever he found useless or rather injurious. 
Nevertheless, he speaks favorably of an extemporaneous hydrargyrum cum 
creta, prepared by triturating blue mass and prepared chalk together into 
a powder. He gave this as an aperient, when such a medicine was required, 
and, combined with opium, found it decidedly beneficial in checking the 
diarrhoea. The pneumonia was treated with fomentations, cataplasms, 
blisters, opiates, and mucilaginous drinks, to the exclusion of all other inter- 
nal remedies, and the use of the lancet. To relieve the delirium he resorted 
to blisters and sinapisms over the spinal axis. Throughout the disease he 
allowed his patients to drink cold water ad libitum, and applied it freely 
to the surface of the body, and never saw it excite either rheumatism or pneu- 
monia. As to narcotics and stimulants — he found opium valuable, but saw 
no benefit from the sulphate of quinine; he also used camphor, carbonate 
of ammonia, and alcoholic compounds, being on the whole favorable to a 
stimulating rather than a depleting course of treatment, but has not stated 
the circumstances and results in such a manner as to be transcribed. 

10. Dr. Dawson has not spoken of the occurrence of a cutaneous eruption 
in this fever, nor has he reported any post-mortem examinations. 



SECTION VII. 

IN AND AROUND LANE THEOLOGICAL SEMINARY. 

I. On what are called the Walnut Hills, about two miles to the northeast 
of the centre of Cincinnati, within half a mile of the margin of the Ohio 
River, and at an elevation of 320 feet above high water mark, is the literary 
institution denominated Lane Theological Seminary. The principal edifice, 
a brick building three stories high, is divided into dormitories, each of 
which has a single window and accommodates two students, who study and 
lodge in it. In the neighborhood there are many families who live in com- 
fortable circumstances. 

The Seminary was opened about the year 1832. The diet and lodgings 
of its inmates had at all times been of the simplest character. The majority 
of these ate but little meat, and a few refrained from it entirely ; of course 
none of them drank any kind of alcoholic beverage. The same individuals 
generally remained two or three years. Early in the autumn of 1842, the 
epidemic began, and new cases began to occur till the last week of Decem- 
ber, when they amounted to twenty-four, among the pupils, who then num- 
bered sixty, and eight among the children of the neighborhood, in families. 
The physician who attended the greater number of the former, was Dr. Dodge, 
of Cincinnati, but Dr. Carroll, whose account of a similar fever in the eastern 
part of Ohio, has been already analyzed, was called to Dr. Dodge's assis- 
tance, and is the historian of the epidemic* 

* Western Journal, vol. viii. p. 321. 



INTERIOR VALLEY OP NORTH AMERICA. 393 

II. Rise and Spread op the Fever. — The first patient was a young 
man who had spent some months in the northern part of the state of Indi- 
ana, and was seized in the month of September soon after his return. The 
next had been travelling in Illinois, and was taken down in a week after he 
reached the Seminary, in the same month, and did not recover till the last 
of November. The third case did not occur till the first of the latter month, 
after which for eight weeks new cases appeared every few days. Several 
of the students boarded and lodged in private families, and with one excep- 
tion escaped the fever. Six or seven being confirmed Grahamites, that is 
exclusively herbivorous, boarded themselves, and all except one experienced 
an attack of the worst kind. The individual who escaped was older than 
the rest, and was said sometimes to indulge himself in the use of meat. 
Of the eight children, six belonged to families who had received patients 
from the Seminary, but the other two were boys, not known to have had any 
communication with the sick. All the physicians who waited on the sick 
escaped the fever, except Dr. Dodge, whose attendance was greater than that 
of all the rest, and he was not taken down till the 27th of January, four 
weeks after the last case in the Seminary. The number of deaths was two. 

III. Prominent Symptoms. — These I shall give in the words of Dr. 
Carroll : — 

"At first, most of the cases began with slight indisposition, which gene- 
rally continued but a few days; headache was a frequent symptom, and 
lasted for two or three days more, and then a chill of some hours duration 
completed the formation of the fever. During the whole forming stage, 
slight chilliness was experienced, particularly at the approach of night. The 
skin was mostly dry, though there was in a few cases partial sweating, which 
generally occurred at night. This condition of the surface, however, did 
not last long; it became dry, and yielded to the touch that peculiar sensa- 
tion which so generally belongs to typhoid fevers. The pulse was quick- 
ened and more resisting than natural, and there was occasionally slight 
nervous disturbance, that sometimes continued either in an undiminished, 
or aggravated form, throughout the disease. The fever might now be said 
to be completely formed, and continued a longer or shorter time according 
to circumstances. A few recovered completely in two weeks, whilst others 
were down from twenty days to three months. Most of the patients were 
convalescent in twenty-eight days. Through the first ten days, the tongue 
was mostly slimy and covered with a white fur, which after some time 
became brown on the centre and back part. In a few cases the organ had 
a chapped appearance ; in two or three only was it red ; and in two cases 
dryness supervened. One or both of these conditions was present in two 
cases that proved fatal. 

"The urine in most cases was scanty and high-colored, and in a few was 
voided with difficulty towards the termination of the disease. The face was 
frequently flushed, but sometimes little alteration could be observed : this 



394 THE PRINCIPAL DISEASES OF THJ 

symptom was, however, more frequent during the advanced stages, or after 
the first ten days. It often appeared day after day on but one cheek, and 
in the afternoon. It mostly preceded sweating a few days, but when this 
supervened, it subsided for some hours, and reappeared on the following 
afternoon. The pulse generally exceeded its natural frequency from ten to 
twenty strokes per minute. In some of the adults it was one hundred and 
forty, and in children occasionally more. It was generally regular, full and 
round, without much tension j in a few cases it was irregular, vibratory, 
tense, and sometimes feeble, though mostly resisting. In two of the fatal 
cases, the pulse was regular, round, and not hard until near the last. The 
hearing was affected in but few patients j in three of the fatal cases it was 
imperfect. Towards the termination of the fever sweating was frequent, 
though not universal, and had generally the effect of mitigating the fever ; 
indeed, in many cases, it seemed to be the mode by which the disease left 
the system. 

"The understanding remained clear for the most part, yet there were six 
patients in whom delirium supervened at some period of the fever. Slight 
wandering occurred in others, and was present, in a greater or less degree, 
in all the cases that terminated fatally, though not through the whole course 
of the disease. 

" Sudamina appeared in six patients only, and in but one of those that 
terminated fatally; but the lenticular spots, considered essential to the 
typhoid fever of Louis, Chomel, Bartlett, and others, appeared in a well- 
marked form in but two cases. Both of these were children, one eight, the 
other four years of age. It is true, that there was in a few cases an erup- 
tion, but it was not of the kind that is considered essential to typhoid fever. 

" There was either diarrhoea, or very easily excited bowels, in a large num- 
ber of cases ; indeed there were but few exceptions. The discharges per 
anum were generally of good color, but not consistent; and hemorrhage, 
so much to be dreaded, occurred in two cases only, which will be noticed by 
and by. Meteorism, and gurgling on pressure, were present in most of the 
cases ; the former, in particular, to a greater or less extent in nearly all. 

"This condition is not always brought about by unassisted morbid action, 
but in my humble opinion, by the mode of treatment, both as regards 
medicine and diet. Soreness on pressure over the region of the ileo- 
coecal valve, could be discovered in most cases ; and sometimes there was 
diffused tenderness over every part of the abdomen, though this symptom 
was by no means common. In a few patients there was irritation of the 
stomach, and medicine was retained with difficulty : this organ, however, 
mostly bore with ease whatever was taken. Most of the patients had con- 
siderable thirst, and desired cold drinks. Abdominal pains were not unfre- 
quently present, and in a few cases were severe ; bleeding from .the nose 
was not an uncommon occurrence towards the close of the fever. " 

This, also, I shall transcribe from Dr. Carroll's account. 



INTERIOR VALLEY OF NORTH AMERICA. 395 

" I did not see any of the cases until the 25th November ; after that period, 
I attended all of them, in conjunction with Dr. Dodge, until the 27th 6f 
January, when the Doctor was seized with the same disease. I then attended 
alone until it disappeared in his case, about the 1st of April. Anterior to 
the time I was called, Dr. Dodge had attended all the cases, but occasionally 
had the advice of Drs. Mussey and Worcester. Dr. Dodge and myself 
usually made alternate visits, and compared notes every evening, so that the 
treatment was conducted with a perfect understanding of what each had done; 
thus a very steady course was pursued throughout. 

"One of our first objects was to see that the patients had apartments suffi- 
ciently large and well ventilated ; and that their bed and body linen should 
be frequently changed. In accomplishing these objects we experienced but 
little difficulty, as a number of those who fell sick were kindly invited to 
the houses of the professors, or wealthy neighbors, where every friendly office 
was promptly and cheerfully performed. Those students who were not sick 
became nurses in turn, so that proper attention was paid, both by day and 
night. It may be added, that as all the adult patients had well-cultivated 
minds, and had arrived at definite conclusions as to the prospects of a future 
state, calmness, without unnecessary despondency, was manifested in every 
case, so far as I know. 

"When at the outset we found our patient with a strong, hard, and frequent 
pulse, or indeed when the frequency was but little if any above the natural 
standard, with accompanying headache, and flushed face, we bled to ap- 
proaching syncope; immediately after, the warm dash was used, or sometimes 
warm sponging, and in a few cases the cold dash was administered either over 
the whole surface, or on the head alone. The next object was to purge freely 
by giving from ten to fifteen grains of calomel, and following it in half an hour 
or more with a free dose of salts, jalap, or oil. I was, myself, favorable to the 
use of jalap, and therefore gave it, in preference to the other articles. After 
thus reducing the system, it was agreed to direct the warm shower or sponging 
every few hours during the first several days ; and afterwards less frequently. 
I felt anxious that all the patients should take tartrate of antimony in minute 
doses, throughout the disease, until the approach of convalescence or sinking ; 
if these irritated the bowels or stomach, opiates were to be added, or used 
to prevent it ; and in those cases in which the diarrhoea was difficult to con- 
trol, the antimony was to be discontinued. Occasional small doses of calo- 
mel were thought proper ; where there was irritation of the bowels the blue 
pill was substituted in its stead. 

"In prescribing mercurials it was not our object to affect the salivary glands, 
though a gentle action we did not fear ; we had little or no confidence in its 
removing the fever, however much it might mitigate the symptoms. When 
diarrhoea should appear, it was our purpose to allay it by Dover's powder, 
soda, &c. Aperients were to be used when admissible, but no active purg- 
ing should be induced after the first days of the fever ; one, two, or three 



396 THE PRINCIPAL DISEASES OF THE 

evacuations daily it was thought would be sufficient. My own predilections 
led me to favor the use of jalap or Epsom salts for this purpose. Dr. Dodge 
preferred salts, while Professor Mussey had a very decided opinion in favor 
of rhubarb and soda combined; in cases of debility this combination had a 
good effect. Often no cathartic medicine was administered for days in suc- 
cession. Emetics we occasionally tried, and found them beneficial in seve- 
ral cases ; in one, however, vomiting had an unfavorable effect. Probably 
no certain rule can be laid down to govern the use of emetics in fever ; and 
in those of a remitting or intermitting type, they not unfrequently 
seem to act disadvantageously ; in continued fevers, however, they operate 
with more advantage. 

" When the abdomen was in a meteoric state, with or without tenderness, or 
the bowels painful, fomentations of various kinds were prescribed, with dry 
cupping, blistering, &c. ; scarifications with cupping were resorted to in a 
few cases. For pain in the head, or more serious affections of it, cold appli- 
cations to the scalp with blistering, &c, were resorted to ; the latter was of 
much service, the former more problematical. It may be proper to observe 
that in cases where bleeding was resorted to more than once, the patients 
were not benefited by the second operation ; indeed I am opposed to bleed-, 
ing after the first week, except in a few rare cases. I do not recollect that 
I have ever known a patient to recover, who was largely bled at a late period. 
"Whatever brings the pulse below the natural standard in point of strength, 
has had, so far as I have observed, an unfavorable effect. At the outset we 
concluded it was only proper to moderate the force of the morbid action, 
rather than attempt to cut it short; as we considered the disease in a great 
measure of a self-determined character. 

" It will be admitted that in a disease where there exists local lesions its 
force would benefit or prevent the progress of those lesions; and by this 
means enable the system to overcome the fatal tendency that otherwise 
would attend such lesions. Hence the benefit of moderating the force of 
the circulation in this fever. Advantage would then be derived from various 
means, as bloodletting, laxatives, diaphoretics, &c. But of all the means 
within the reach of the profession none seems to me equal to the tartrate of 
antimony, when given in such way that the stomach shall not be disturbed 
by it, yet that the circulation shall be brought under its control, which will 
be known by the pulse becoming less frequent, less hard, and less con- 
stricted, or more natural in its action. Small doses will, when continued 
during several days, gradually bring the action of the heart and its arteries 
under its influence, so that the frequency of the pulse will be lessened two 
strokes or more per minute, at the same time that all the other symptoms 
will be mitigated — the skin will be more natural, the heat more regularly 
diffused, headache, if it exist, will be moderated, and the various secre- 
tions more normal." 

In a subsequent part of his paper Dr. C. makes the following important 
remark : — 



INTERIOR VALLEY OF NORTH AMERICA. 397 

" Anterior to 1834, I had never known a case of this fever recover in 
which hemorrhage had taken place ; and I had uniformly found that daily 
purgation had been advised and pursued. This fact led me to the conclu- 
sion that purgative medicines should not be given in such cases. I accord- 
ingly determined that I would in the treatment of a number of cases, should 
they occur to me, avoid all laxative medicines, and that I would keep the 
peristaltic action quiet through a number of days. This determination I 
have carried out in the treatment of a considerable number of cases during 
the last nine years, and I have not as yet been disappointed." 

After detailing the history of a number of cases illustrative of the benefit 
of this treatment, Dr. Carroll proceeds to give an account of five cases, four 
of which terminated fatally, and the fifth recovered with difficulty, in which 
bloodletting was either omitted, partially employed, or deferred to a late 
period of the disease, which brings us to the 

TV. Morbid Appearances after Death. — Case I. Mr. Olney, who 
had for several months lived on a diet exclusively vegetable, sickened on the 
1st of December, after several days of unclefinable indisposition. The disease 
was rapid in its course, and early in its termination. His pulse was 120, full, 
and hard, but he refused to be bled. On a subsequent day, when delirium 
had come on, Dr. Dodge drew a quantity of blood from a branch of the tem- 
poral artery, which was followed by some mitigation of his symptoms. 
From the beginning, he had labored under subsultus tendinum. Sudamina 
appeared on his neck and chest, but no rose-colored spots. In the latter 
stage of his disease, diarrhoea supervened. 

On dissection, nineteen hours after death, the arachnoid was found opaque 
and adherent throughout to the pia mater, which was unusually vascular ; the 
cerebral substance exhibited numerous red points, but there was no effusion. 
In the lower six inches of the ileum, several elliptical patches projected a 
line or more above the level of the mucous membrane, and a few of them 
presented small ulcers. The mesenteric ganglia, connected with the diseased 
ileum, was enlarged, but not vascular. The spleen increased in size, was 
extremely pliable. No disease was found in the stomach, lungs, liver, or 
other parts. 

Case II. Mr. Kidder, who for some time had lived on^a diet of brown 
bread, potatoes, apples, and water, was taken ill on the 4th of November. 
There was nothing remarkable in his symptoms, but on the 10th of Decem- 
ber, a meteoric condition of his abdomen, whieh had existed in a slight 
degree from the beginning, suddenly increased, with tenderness and gurgling 
on pressure. At the same time a swelling in the perineum, extending to 
the left hip was discovered. On the sixteenth, a spontaneous opening 
occurred, anterior to the anus, on the right side of the raphe, and a copious 
discharge of pus and fasces followed, terminating in diarrhoea. He had in- 
voluntary discharges of urine, and on the 22d a copious discharge of blood 
from the bowels. From the 5th to the 22d of January, he had cough and 



398 THE PRINCIPAL DISEASES OP THE 

severe pain in the right side of the chest. This was followed by paralysis 
of the left side, with an abscess of the brow of that side. Meanwhile, cir- 
cular inflamed spots, terminating in little abscesses, and sloughing ulcers, 
appeared on the trunk of his body. Finally, two artificial openings were 
made, one about two inches from the anus, the other below the left trochanter, 
through which pus, feces, and sloughs of cellular membrane were discharged. 
Before this time, the symptoms of the original fever, had, of course, disap- 
peared, and for a while he seemed to be convalescent, but on the 15th of 
February he died. 

In the post-mortem inspection of this remarkable case, Dr. Carroll was 
assisted by Dr. Warden and Dr. Lawson., They were not permitted to exa- 
mine the brain. In the dorsal portion of the spinal cord, they found no 
disease. The left lung was in a state of adhesion, with a few ounces of 
effused fluid, and its inferior lobe was impervious. The upper part of the 
right lung was tuberculated. The viscera of the abdomen were in a state 
of atrophy. The stomach seemed nearly natural. The valv. conniv. were 
thickened and contracted. The solitary glands of the ileum appeared to have 
been inflamed; those of Peyer could scarcely be detected. In the head of 
the colon there was a cicatrized and an uncicatrized ulcer. The bladder was 
contracted and thickened in its serous and cellular coats. The mucous coat 
of the lower part of the rectum was in a state of thickening and congestion, 
and about an inch and a half above the sphincter on the left side there was 
an aperture that would admit the finger, through which the fasces had passed 
into the cavity of the perineal abscess. 

Case III. Henry G-oodman, twelve years of age, died in twenty days from 
the time of his attack. There was nothing remarkable in his symptoms, till 
about the sixteenth day of his disease, when, after having had a discharge 
from his bowels, he complained of severe abdominal pain. The next day 
his abdomen was swollen and tender, with a disposition to vomit, and labori- 
ous breathing. Four days afterwards he died. 

Eighteen hours after death Dr. Dodge and Dr. Carroll examined the body. 
The peritoneal cavity contained lymph and feces, and the intestines were 
agglutinated together. Some of the mesenteric ganglia were enlarged, and 
one of them contained a quantity of pus. The spleen was enlarged, blue, 
and tender. The lower fourteen inches of the mucous membrane of the 
ileum was of a dark venous hue, in the centre of which was a perforation large 
enough to admit a quill. It did not appear to have been within one of the 
oval plates, many of which below the aperture were perceptible, but seemed 
in a healthy condition. " The lungs were in a morbid condition. " No 
lenticular spots or sudamina were perceptible on the body, either before or 
after death. 

Case IV. Master Goodman, aged nine years, the brother of the foregoing, 
had been for some time apparently affected in the lungs. His mother had 
long been afflicted in that way. He was seized on the 1st of January, and 



INTERIOR VALLEY OF NORTH AMERICA. 399 

died on the 18th, having had the usual symptoms, — mild delirium, coma, 
and meteorism, with quick and laborious respiration. On examining the 
body sixteen hours after death the spleen was found enlarged and easily 
broken down ; through the space of three feet, the elliptical plates of the 
ileum, were all in a state of ulceration, without raised edges but excavated 
down to the muscular coat. The ulcerated spots and the surrounding 
mucous membrane were pale. The right lung was hepatized in its lower 
part, and in a state of congestion throughout, surrounded with six or eight 
ounces of lymph and serum. The left lung was nearly sound, but the pleura 
of that side contained two or three ounces of fluid. 

V. No other deaths occurred, and consequently no other post-mortem ex- 
aminations were made. Referring to these in connection with the conclu- 
sions of Louis, Dr. Carroll has the following remarks : — 

"In the case of Olney, the elliptical plates were diseased in the manner 
laid down by Louis, as essential to this form of fever; but the mesenteric 
glands were not affected in the way that this distinguished pathologist thinks 
necessary to typhoid ; for instead of being rose-colored and softened, what 
few of them were at all diseased, were white in the centre, and much 
harder than usual. He had no lenticular spots nor sudamina. Death re- 
sulted in this case not from the condition of the abdominal viscera, but from 
that of the brain and its membranes. 

"In the two cases that occurred in Mr. Goodman's family, it has been 
observed that the lesions were different. Neither of the patients had lenti- 
cular rose-colored spots, nor sudamina; but one had ulceration of Peyer's 
glands ; yet the mesenteric glands were almost, if not altogether, free from 
disease. In the other, the elliptical plates were healthy, but there was a 
congested or inflamed mucous surface in a small part of the ileum, and that 
part of the mesentery connected with it, and several of the glands were 
affected in the manner Louis thinks essential to typhoid. Kidder's case 
seems to demonstrate that the elliptical plates really had never been dis- 
eased; but that the isolated follicles had been inflamed, though not ulce- 
rated. Here, also, the mesenteric glands were found apparently healthy." 

In the latter part of his paper, Dr. C. discusses the question whether this 
epidemic should be called typhus or typhoid according to the attempted dis- 
tinction of certain writers, and comes to the conclusion that it combined 
many of the characteristics of both, without conforming fully to the defini- 
tion of either. 



SECTION VIII. 

INDIANA AND ILLINOIS. 

The prevalence of these fevers seems to be far less in the states just 
mentioned, than in Ohio. They are of more recent settlement, are less ele- 



400 THE PRINCIPAL DISEASES OF THE 

vated above the sea, and more infested with autumnal fever. In respectable 
communications from gentlemen residing at various points in the basin of 
the Wabash, whose names are mentioned in the topographical part of this 
work, I find scarcely a reference to the fevers we are now studying, except 
when they speak of the termination of occasional cases of remitting autum- 
nal fever in a train of typhous symptoms. These secondary typhous affec- 
tions, as we shall hereafter see, are occasional occurrences in every part of 
the Southern or Mexican Basin, and appear to be more frequent in some 
other regions than the one we are now considering. 



CHAPTER IV. 

LOCAL HISTORIES OF TYPHOUS FEVERS: SOUTHERN BASIN; KENTUCKY. 



SECTION I. 

IN BOURBON COUNTY. 

That part of Kentucky which lies within and northeast of the basin of 
the river which bears the name of the state, has never been much affected 
with autumnal fever. Its surface is the driest, and it has N been longest 
settled, the first emigration being about the year 1775.* From the begin- 
ning, sporadic cases of typhus fever have occurred; and autumnal remittent 
has at all times shown a tendency to a continued type. Within the last 
twenty or twenty-five years, the cases have multiplied, and many local epi- 
demics or sub-epidemics have occurred. I will give an account of two which 
may represent the whole. 

I. Epidemic in Paris. — In the spring of 1845, I made a visit to Paris, 
Bourbon County, and collected from Dr. J. A. Ingels the following account. 

The town is built immediately above the junction of two lagging mill- 
streams, Stonen and Hueston, which discharge their confluent waters into 
Licking River, through its south fork. They flow through narrow valleys, 
with rocky limestone beds. The town is as elevated as that of the country 
which surrounds it. 

II. History. — According to Dr. Ingels, the fever began in the autumn 
of 1839, and continued to occur through the months of December and 
January. In February it declined, and in March ceased altogether. For 
two years before its appearance, that region had suffered from drought to 
such a degree, that springs and wells which never failed before, were dried 
up ; and the streams which flow near the town were remarkably low and 
stagnant. 

* See vol. i. p. 249-56. 



INTERIOR VALLEY OF NORTH AMERICA. 401 

It was confined to the town, affecting both blacks and whites, the rich 
and the poor, and both sexes, indiscriminately. It was estimated that cases 
occurred in at least half the families of the town. Young persons were 
more obnoxious to it than the aged. Dr. Ingels' youngest patient was four 
years old. In general, the patients were under puberty, yet a number were 
between forty and forty-five. It seldom attacked the whole of a large 
family — in most instances, one, two, or three only. 

After the spring of 1840, sporadic cases only occurred in town, but it 
spread into the surrounding country ; where up to the time of my visit, five 
years afterwards, it continued to prevail more or less, as an endemic. As 
late as the autumn of 1844, Dr. Ingels saw twelve or fifteen cases in a 
single family. His opinion was, that it spread by contagion ; but I did not 
collect the facts on which that opinion rested. 

III. Symptoms. — The fever generally made its attack in a gradual 
manner. The prominent symptoms of the forming stage were slight but 
protracted or frequently-recurring chilliness, a rapid pulse, lassitude, a 
whitish tongue, which sometimes displayed unnatural redness along its edges 
and tip, in most cases impaired appetite, dull headache, often a pain in the 
umbilical region ; bowels either regular, or affected with diarrhoea, which, 
moreover, was often produced by cathartic medicine. 

When the fever was established, the intensity of the heat was various. 
The pulse was oftener soft or natural in force than hard ; its frequency was 
permanent and characteristic, being, generally, above one hundred; in a 
lady, forty-five years of age, it did not vary, for two weeks, more than five 
beats from one hundred and forty in a minute. There was seldom much 
nausea ; the liver acted well, and the alvine discharges in almost every case 
were more or less bilious, but in many, they were sero-mucous. Coma, de- 
lirium, and subsultus tendinum were rare \ noise and light produced but 
little impression ; the nights were generally restless. In some cases there 
was a cough. There was commonly a circumscribed flush on one cheek. 
In a few cases a vesicular eruption (sudamina), on the upper extremities. 
The average duration of the fever was about four weeks. No post-mortem 
inspection was made. 

IV. Treatment. — xllthough often consulted in the forming stage, Dr. 
Ingels did not succeed in arresting the fever in a single instance ; nor, when 
fully formed, did any method of treatment produce that effect. Antimonial 
emetics, occasionally tried, were injurious by exciting diarrhoea. Ipecac, 
was less objectionable, but did not break the fever. All active purging did 
harm. A salivation was not often tried, for mercurials seemed to promote 
hemorrhage. Venesection was employed in a few cases, but without appa- 
rent benefit. In short, Dr. Ingels found all active treatment injurious, and 
was led to rely chiefly on the following : Abstinence from stimulating food 
and drinks, confining the patient to herb teas, gruel, and rice-water ; abdo- 
minal fomentations and foot-baths, dry cupping, and sometimes scarification 

vol. ii. 26 



402 THE PRINCIPAL DISEASES OF THE 

of the abdomen ; occasionally blistering of the same part ; gentle aperients, 
such as the oleaginous mixture, alternated with gentle doses of calomel or 
the blue mass, and followed by small portions of acetate of morphia and 
ipecacuanha. The most dangerous symptom was diarrhoea, especially when 
the discharges were of a sero-mucous character. To relieve it, he found 
perfect rest and constant recumbency of great importance. Internally, opium, 
ipecac, acetate of lead, and nitrate of silver, were found beneficial. When 
checked, he would allow his patients to pass four, five, and even six days 
without an evacuation. Another troublesome symptom was intestinal hemor- 
rhage, which was more common in the country than the town. It was 
checked by the same means as the diarrhoea. About one in twenty of Dr. 
Ingels' patients died. 

The symptoms and effects of remedies seem to characterize this epidemic 
as typhus fever, whose ravages fell chiefly on the bowels, the brain and 
lungs suffering comparatively but little j and hence it seems to have been 
allied to the typhoid affection of Louis. 



SECTION II. 

IN SCOTT COUNTY.* 

1. Origin and Spread of a Subepidemic.-j- — According to Dr. Sutton, 
for almost a year before this fever could be said to be epidemic, it occurred 
sporadically in Greorgetown, the county town, and its vicinity. Of its 
origin he declares lie knows nothing, as no local or temporary causes were 
observed to exist. On its dissemination he speaks with reserve, as in 
numerous cases it could not be referred to contagion, while in several that 
mode of propagation seemed manifest. I shall present a condensed account 
of these cases. 1. During the early part of the winter of 1845-0, when the 
fever was prevailing in Georgetown, Miss S. left it, indisposed, for a neigh- 
boring village of the county, called the Stamping-ground, where the disease 
did not exist. The fever was soon developed in her system and proved 
fatal. The fever quickly spread throughout the village, and it was believed 
that most of the first cases could be traced up to communication with her. 

2. About the same time Mr. W. S. sickened with the fever in town 
and was removed to his father's, a mile in the country, where no case had 
as yet occurred. The attack was protracted and ultimately fatal. Some 
weeks after his death two of his brothers were severely attacked, and during 
their convalescence, two other brothers and two sisters sickened with the 
same fever and were ill at the date of the report. 

* See vol. i. p. 252. No. VII. 

f This account has heen condensed from a MS. Report, by Dr. W. L. Sutton, to an association of his 
brethren, on the 11th of March, 1846. Since favoring me with the use of his manuscript, it has been 
published in Louisville by Maxwell & Co. and constitutes the most complete history which has been put 
forth, of any of our local typhous epidemics, 



INTERIOR VALLEY OF NORTH AMERICA. 403 

3. In addition to these facts furnished by the recent epidemic, Dr. 
Sutton recurs to the year 1841, when the fever prevailed in some parts of 
Scott County, and narrates the following. Miss. C. made, it was said, an 
occasional visit to the family of a relative who resided four miles from her, 
and was affected with the fever. On the 17th of May she herself was 
attacked, but recovered after a lingering illness. About the 20th of July, 
her mother and four negroes were seized, within a few days of each other; 
and on the 22d of August another negro was taken down. The negroes 
were all of one family, — a mother and four children. Dr. Sutton justly re- 
gards these as examples apparently of contagious dissemination ; but remarks, 
on the other hand, that in an overwhelming majority of cases, no evidence 
of such propagation could be detected. The cases, he continues, were usually 
solitary, and scarcely ever were there more than two or three in the same 
family. 

II. Symptoms and Progress or the Fever. — The attack commenced 
frequently in the most gradual manner, and was characterized by symp- 
toms not well defined nor easily expressed ; the debility of both body and 
mind was however decided, with great disinclination to every kind of effort. 
In other cases, however, a person in good health was suddenly seized with a 
chill, accompanied with pain in the head, back, and limbs, followed by early 
febrile reaction. 

Abdominal Symptoms. — In the beginning, the tongue in many cases 
was natural ; but in others covered with white fur, through which red 
papillge projected, the edges and tip presenting the same color; with dimi- 
nished moisture, and impaired sense of taste. As the disease advanced it 
became clammy and covered with a dark crust, which cracked in various 
directions, and the edges of the organ assumed a deeper red. About the 
same time, the lips lost their plumpness and moisture, and often cracked 
open; sordes collected on the teeth; and the patient manifested a disposi- 
tion to pick his mouth and nostrils. Frequently there was redness, and on 
swallowing, a feeling of soreness in the throat with great thirst. The appe- 
tite was sometimes lost, and very generally impaired; but cases occurred 
in which it continued with but little diminution throughout the whole 
course of the disease. Nausea and vomiting occurred in a few cases only. 
Diarrhoea frequently began several days before the patient took to his bed; 
but if then absent scarcely ever failed to supervene in the course of the 
disease, and constitute a prominent symptom. It varied from one or two, 
to fifteen or twenty liquid stools in the course of the day — varying much in 
quantity, consistence, and color. Sometimes they were but semi-fluid, then 
as serum, which they resembled in color, though generally they displayed 
some shade of green or yellow, indicative of a continuance of the biliary 
secretion. On the whole they resembled in consistence and color new cider. 
Occasionally they were composed almost entirely of mucus ; sometimes of 
mucus, pus, and blood. With the progress of the fever they exhaled an 



404 THE PRINCIPAL DISEASES OF THE 

abominable, even cadaverous, odor. A few children discharged a considerable 
number of worms. In several cases when the fever was at its height, a large 
quantity of grumous blood was discharged from the bowels; which more- 
over was not the only kind of hemorrhage, for epistaxis was common. In 
the earlier stages of the fever, this was generally slight — in the more 
advanced, often profuse and alarming. There was commonly some abdomi- 
nal soreness and tenderness under pressure, which was greater in the epi- 
gastrium and right iliac region than elsewhere. On pressing over the latter 
a gurgling noise was heard. After the first few days a certain degree of 
tympanitis was common, and not reducible by evacuation from the bowels. 
In a few instances the discharge of flatus was immense. 

State of the Circulation. — When a decided chill ushered in the fever, 
the pulse was full and active, and continued so for a few days, espe- 
cially in the afternoon ; but when the chill was slight, the reaction of the 
pulse was always less. The chills never recurred at regular periods, and 
after the first were not of a marked character. In one case, the pulse varied 
but little from fifty beats in a minute through the whole course of the fever; 
and in mild cases was in general but little beyond its natural frequency. 
In the progress, however, of all the severer cases it rose to 100, 120, 140, 
or even more in a minute. It was commonly from five to ten beats in a 
minute more frequent in the afternoon than the morning, but in many 
instances it was nearly uniform throughout the twenty-four hours. As the 
fever began to decline, it generally abated rapidly in frequency, and soon 
fell to its natural state. 

State of the Nervous System. — In many cases the physiognomy of 
the patient was placid and natural throughout the whole course of the 
disease, even when the issue was fatal. In others, there was a marked ex- 
pression of anguish, which, however, sometimes ceased before death, and 
the patients affirmed that they felt very well. Many cases were attended 
with very little pain, and in those in which it occurred, it generally wore 
away with the first eight or ten days of the fever. Its seat was commonly 
the head, back, or extremities. The great muscular weakness of the form- 
ing stage already mentioned, in almost every case continued throughout the 
whole course of the fever. In some instances, it seemed in fact to consti- 
tute almost the whole disease. The patient would look and say that he 
felt well, but could not sit up. In the progress of the severer cases sub- 
sultus tendinum was apt to supervene. There was usually, in the earlier 
and middle stages of the disease, a morbid sensibility to light and sound, 
with tinnitus aurium, and inordinate wakefulness ; but in the progress of 
the disease, partial deafness, somnolence, and slow respiration supervened. 
The state of the mind in the beginning of the disease was that of debility 
rather than perversion — the patient could not remember or distinctly state 
what had passed. To this succeeded low muttering delirium, especially at 



INTERIOR VALLEY OF NORTH AMERICA. 405 

night; and in a few instances furious aberration of mind, which seemed 
maniacal. 

State of the Skin. — In the earlier days of reaction the heat of the skin 
was generally decided, and in most cases, there was throughout an evening 
increase above the natural temperature. In many, however, after the first 
days, the heat often fell and remained at, or even below, the standard of 
health ) especially that of the elbows, knees, and feet. In general the skin 
was dry, but not husky. 

" Rose-colored, lenticular spots" — answering to the description of Louis — 
were not seen ; but in a few instances there was an eruption of red spots, of 
no uniform shape, on various parts of the body ) which however did not 
suggest the " typhoid eruption" of that author. In some cases a " free 
crop of sudamina" appeared ; in others there was an extensive desquama- 
tion of the cuticle, both where and where there had not been sudamina. 

State of the Urinary Secretion. — In general this function was but little 
altered. In a few cases, the discharge was tinged with blood ; in others 
there was retention. 

Thoracic Symptoms. — These were in general either slight or altogether 
absent. When cough occurred, it was generally such as seems to be excited 
by gastric or intestinal irritation. The respiration was occasionally acce- 
lerated, with a sudden expiration. In a few instances, as the disease 
advanced, a mucous rattle was heard. 

Prognosis. — Great frequency of pulse ; protracted, profuse or obstinate 
diarrhoea ; rapid and irregular respiration ; copious hemorrhage in the latter 
stages of the disease ; subsultus tendinum, delirium, raving, and great 
restlessness, were symptoms of evil omen, to which might be added an im- 
pression on the part of the patient that he was better when some of these 
sinister symptoms were present. In some cases good and bad symptoms 
were singularly blended. Many cases terminated in health after a number 
of alarming symptoms had appeared ; and some proved fatal after apparent 
amendment for several days. In two of these the symptoms indicated peri- 
tonitis from perforation of the bowels, but no post-mortem examination was 
permitted. In the latter periods of a violent case, the epistaxis was so 
profuse that the pulse became extremely frequent and feeble, and the 
muscular strength was almost exhausted, and still, after the hemorrhage 
was restrained by plugging the nostrils, the patient recovered rapidly. 

III. Appearances after Death. — Dr. Sutton has made but two post- 
mortem examinations in this disease, one of which was in 1841. The pa- 
tient, a negro woman aged forty-five years, was ill for twenty-four days, with 
well-characterized vascular, nervous, and intestinal symptoms. On dissec- 
tion twenty hours after death, he found the stomach healthy, except a small 
spot of minute red dots. The small intestines, contracted in several places, 
were otherwise natural, except the lower portion of the ileum, which seen 
externally was dark and contracted. On laying it open, a number of ulcers, 



406 THE PRINCIPAL DISEASES OF THE 

varying in size from the circumference of a grain of wheat to that of a twelve 
cent piece, were discovered. They reached down to the peritonea] coat. 
The small ones had elevated edges, but the larger not. The intervening 
mucous membrane abounded in enlarged veins, filled with black blood. In 
the caecum, upper part of the colon, and lower part of the rectum, ulcers 
were numerous. The calibre of the colon throughout was much diminished, 
and its mucous lining extremely dark. It contained a small quantity of 
semi-fluid faeces. Some of the mesenteric ganglia were enlarged, and por- 
tions of the mesentery were beautifully injected. There was very little 
blood in the vena cava, and the venous system generally was extremely 
empty. The omentum, pancreas, and liver were sound ; but the spleen was 
enlarged and soft. The brain and lungs were not examined. The appear- 
ances in the other dissection were substantially the same. 

IV. Treatment. — Venesection. — Dr. Sutton saw the lancet employed in 
three cases only. In one it did not seem to do either good or harm ; in an- 
other it was followed by alarming debility ; in the third it was employed at 
an advanced stage of the disease, and the patient died. He has not men- 
tioned the appearance of the blood. Discouraged as to the use of the lancet, 
he was induced to resort to cupping, which he found beneficial. 

Emetics were not often employed, but in the early periods of the fever, 
when there was a sense of gastric oppression, with nausea or headache, and 
there was no tendency to diarrhoea, they did good. In more advanced 
stages, when that tendency was great, emetic medicines passed off by the 
bowels, producing serous and bloody discharges, with great prostration and 
death. 

Purgatives. — These were chiefly administered in the early stages of the 
disease, but even then drastics were avoided. Subsequently great care was 
requisite in their exhibition. Small doses of calomel or the blue mass, as- 
sisted with castor oil, were found the safest. Epsom salts and Seidlitz water 
were occasionally used, but the latter especially was often followed by 
griping and watery stools. Such effects sometimes even followed on the use 
of rhubarb. Dover's powder was found a valuable adjuvant to calomel and 
the blue pill, and tended to prevent hypercatharsis. When the quantity of 
calomel was increased for the purpose of procuring bilious and feculent dis- 
charges, it only increased the serous secretion and made the patient worse. 
When hemorrhage was present, he administered the blue mass, ipecacuanha 
and opium, which appeared to do good ; as also did a dose of fifteen or twenty 
grains of calomel, and a large dose of opium alone ; nevertheless, he saw 
other cases in which no particular treatment was employed, and yet the 
patent did well. As a means of opening the bowels in the latter stages of 
the disease, he preferred injections to everything else. 

Sudorifics did not appear to be of much service, but applications to the 
skin often did good. Sponging it with cold or tepid water when it was too 
warm, was often followed by diminution in the frequency of the pulse and 



INTERIOR VALLEY OF NORTH AMERICA. 407 

a feeling of comfort. When there was a tendency to coldness of the feet, 
a hot pediluviurn, the patient being kept in a horizontal posture, was of 
much utility; and to relieve abdominal pains, warm poultices were found 
efficacious. 

Counter-irritants. — Blisters or sinapisms to the nucha were found to 
relieve the head ; and applied over the abdomen, mitigated the pain of that 
region ; but as a means of diminishing the tympanitis, Dr. Sutton did 
not find them very certain. In some instances they excited intolerable 
strangury. 

Expectorants were occasionally demanded, of which he used mucilage with 
ipecac, and an infusion of seneca root with liquorice. 

Opiates were occasionally administered with saline diaphoretics to ease 
pain, allay irritation and induce sleep. But their greatest value was in their 
restraining the diarrhoea, for which purpose laudanum was given in warm 
water by injection, or solid opium and Castile soap introduced into the 
rectum as a suppository. 

Expectant Treatment. — Dr. Sutton believes that the milder cases of this 
fever might have been left to themselves. They would run a course which no 
treatment could abridge, and at length terminate favorably. They all, 
however, required the vigilant attention of the physician, as those which 
presented the most favorable aspect at first, sometimes assumed a dangerous 
character. This transformation was occasionally most gradual and insi- 
dious. 



SECTION III. 

IN OLDHAM COUNTY. 

I. History. — Dr. D. L. Freeman has favored me with a short account 
of a typhous epidemic constitution which prevailed in this county, which 
lies on the Ohio River, above and adjoining Jefferson County, in which 
Louisville is seated. Being a river county, it is more infested with inter- 
mittent and remittent fevers, than the interior of the state generally. 

The fever commenced in the spring of 1844, and continued as a sub-epi- 
demic through the following summer and autumn. In the summer of 1845 
it prevailed again ; and many other forms of disease took on some of its 
characteristics. In the summer and autumn of 1846, the endemial inter- 
mittents and remittents reappeared; but many cases showed a decided 
gastro-enteric irritability. Dr. Freeman states, in general terms, that a 
majority of the cases proved fatal. 

II. Symptoms. — The onset of the fever was slow and insidious. For 
several days the patient, feeling unwell, would yet keep on his feet ; but 
his strength was failing, and at length occasional chills and rigors occur- 
ring, he would take to his bed. Febrile reaction now took place, with a 



408 THE PRINCIPAL DISEASES OF THE 

frequent, thrilling, but easily compressed pulse, surface heat, urgent thirst, 
and severe pains of the limbs, back and head, especially the last. The 
tongue was generally red, even at an early period of the fever, and when 
fur appeared, it was commonly on the posterior part, with a belt extending 
forward on the middle of the organ. Restlessness and sighing were com- 
mon. The bowels were generally inclined to costiveness ; but pressure over 
the lower and right side of the abdomen gave pain, and excited gurgling. 

If at this time cathartics were administered, the discharges were liquid, 
yellowish, or greenish, and extremely offensive. With the progress of the 
fever, the pulse gained in frequency and lost in force ; the heat of the surface 
became burning j the moisture of the tongue dried up, and sordes accumu- 
lated on the teeth ; diarrhoea supervened, and the thin fetid discharges some- 
times contained mucus dotted with blood. His nostrils often became stuffed 
with hardened mucus, tinged with blood when it was removed ; a majority of 
cases, indeed, were attended with epistaxis. In this stage of the fever his in- 
tellectual functions became greatly enfeebled, with incoherence and subsul- 
tus ; coma occurred, and he would lie with his eyes and mouth half open, being 
obliged to breathe through the latter from the obstructed state of his nostrils. 
When the disease was tedious, ulcers frequently formed over the sacrum. 
In well-marked cases maculte of a petechial character appeared on the abdo- 
men and breast. In cases attended with profuse perspiration, sudamina 
frequently appeared on the neck and chest. 

III. Pathological Anatomy. — Dr. Freeman examined but one subject. 
The disease had been well characterized. The mucous membrane of the 
stomach was injected with blood. In following the membrane down the 
bowels, to the ileum, the hyperemia reappeared. Many of the elliptical 
patches were inflamed and ulcerated, the ulcers having raised margins. 
The mucous coat of the caecum was dark and softened. The spleen was 
engorged to the weight of twenty-eight ounces, and greatly but unequally 
softened, the gastric extremity seeming like a coagulum of blood. Of 
the other abdominal organs, Dr. Freeman makes no report, and examination 
was limited to one of the great cavities. 

TV. Treatment. — The first treatment of this fever was with bloodletting, 
emetics, cathartics, diaphoretics, and a liberal administration of calomel, 
with a view to its effects on the constitution. This method was unsuccess- 
ful if not injurious, for the patients generally died. The bleeding diminished 
the fulness, but increased the frequency of the pulse ; the cathartics promoted 
diarrhoea, and did not improve the quality of the discharges; the calomel 
did not promote a healthy secretion of bile, nor arrest the fever ; while if 
continued long it produced ulcers of the mouth, which in some cases became 
gangrenous j or seemed to occasion suppurative inflammation of the parotid 
glands, always followed by death. Observing these sinister results, Dr. 
Freeman and the physicians of the county generally, abjured this practice 
and employed local bleeding, gentle aperients, mild enemata, counter-irri- 



INTERIOR VALLEY OF NORTH AMERICA. 409 

tants, and stimulating diaphoretics ; under which change of treatment the 
mortality decreased to such a degree, that the profession of the county ac- 
quired a settled conviction that copious bloodlettings, active purges, and 
the free use of calomel, should be entirely rejected. 

The details of the method which Dr. Freeman found most beneficial, are 
the following : When called early, he directed a general warm salt bath, 
with subsequent rough friction of the skin ; the patient then to be placed 
in a well-ventilated apartment, with sufficient bed covering, and the ex- 
clusion of society. In this condition, the excitement in some cases was 
such, that he instituted a liberal venesection. If the patient had been cos- 
tive he gave a mild cathartic aided by an enema. Local bloodletting then 
followed, especially around the base of the skull j the patient's hair was cut 
close and cold water poured on or otherwise applied to the head, and a 
liberal use of demulcent drinks was ordered, with draughts of spiritus Min- 
dereri. Subsequently he cupped over the spine, the epigastrium, and the 
right iliac region, finding such benefit from the practice as encouraged 
him to persevere. He washed the surface of the body with tepid salt water, 
and made subsequent dry friction. When the bowels continued torpid, he 
excited them with enemata. When diarrhoea was present, he administered 
Dover's powder with hydrargyrum cum creta, and opiate injections ; if 
these did not succeed, he applied a blister over the abdomen, and covered 
the surface with irritating dressings. After the early stages of the fever 
were passed, he supported the strength of the patient with liquid diet, wine 
whey, and port wine. In the latter stages he resorted to the usual stimu- 
lants. In this stage, one of his patients became unable to swallow, when 
he injected into the rectum a large quantity of wine with sulphate of qui- 
nine. The patient was roused and recovery took place. In a few cases his 
patients survived involuntary discharges of faeces and urine. One patient 
recovered, after lying eight days insensible to every external influence. 
Another had an enfeebled and at times incoherent mind for several weeks 
after the fever passed away. 

The fever uniformly ran a tedious course, ranging from three to four 
weeks ; seeming to be self-limited j and leaving to the physician nothing 
but the duty of correcting the symptoms and sustaining the patient's 
strength. 



410 THE PRINCIPAL DISEASES OP THE 



CHAPTER V. 

LOCAL HISTORIES OF THE TYPHOUS FEVERS OF THE SOUTHERN 
BASIN, CONTINUED.— IN TENNESSEE. 



SECTION I. 



IN SMITH COUNTY." 



From Dr. F. H. Gordon, I learn that a continued or typhous fever fre- 
quently prevails in this county. The notes with which he has favored 
me relate especially to the disease, as it appeared in the years 1844, 
'5, and '6. It has received the name of winter fever, although it is not 
limited to that season. It affects persons of both colors and of all ages, 
infancy not being exempt. Dr. Gordon has given me the history of 
two cases, a mild and a malignant one, which he says will serve as speci- 
mens of the whole, both in the symptoms and the treatment. The following 
is a condensed narrative of each. 

Case I. Mild. — On the 4th of January, 1846, Cato, a negro boy, was 
attacked, and Dr. Gordon saw him two days afterwards, when he complained 
of head and backache, with muscular tremors, dizziness and great debility, 
nausea, and epigastric tenderness. His feet were cool in the morning, but 
with the surface generally hot and dry the other portions of the day and 
night ; his urine was scant and reddish ; his tongue was red at the tip and 
edges, but covered with white fur in the middle; his alvine dejections 
were rather frequent, and consisted of a yellowish water; his pulse was 
frequent, small, and somewhat corded. He was bled till his pulse became 
fuller and softer ) and ordered to take three grains of calomel and the 
same quantity of Dover's powder, every three hours, till three doses were 
taken. On the next day, January 7th, his evacuations were greenish, liquid, 
and copious — his abdomen painful, tender, and a little swollen. Ordered 
large hot poultices of bran to the abdomen to be renewed every twenty 
minutes, till the pain and tenderness abated ; also half a grain of tartar 
emetic and five grains of sulphate of magnesia every two hours ; and a grain 
of acetate of lead, and three grains of Dover's powder, at short intervals, 
if the alvine discharges should be frequent. Dr. Gordon did not see the 
patient on the 8th or 9th, but on the 10th he found him much better. The 
soreness and swelling of his abdomen were gone ; his alvine discharges were 
feculent but rather thin ; his appetite was restored and he slept well. He 
now discontinued the antimonial, but continued the Epsom salts ; under 
which the recovery was so rapid that on the 14th, ten days from the time 
of his attack, the boy went out on the plantation. 

* See toI. i. p. 236, No. VI. 



INTERIOR VALLEY OF NORTH AMERICA. 411 

Case II Violent— On .the 22d of March, 1846, Dr. Gordon was called to 
W. P., a white boy, eleven years old, who had then been confined for four 
days, during which had complained of dimness of sight every forenoon 
between ten and twelve o'clock. His fever had been continued, with some 
abatement in the latter part of the night. At irregular intervals he had 
rigors. His cheeks were flushed with unnatural whiteness around his mouth 
and nostrils. Still further he had dyspnoea, pain in his head, back, and 
limbs, jactitation, delirium during the exacerbations of fever,intense thirst, 
a red tongue, abdominal tenderness, and frequent discharges of yellow water. 
His pulse was 110 in a minute. Dr. Gordon bled him to fifteen ounces, 
and directed calomel, blue mass, and Dover's powder, each six grains, to 
be mixed and divided into two portions, the second to be taken six hours 
after the first • also one grain of acetate of lead and two of Dover's powders, 
at short intervals, to moderate the action of the bowels. Bran poultices as 
in the other case were likewise directed to the abdomen. Not expecting to 
see his patient for a day or two, he farther ordered, that when three or four 
evacuations had occurred after commencing the use of the calomel, five grains 
of sulphate of magnesia should be given every two hours, till the alvine dis- 
charges became natural. His next visit was on the evening of the 25th, 
when he found that the last item in the prescription had not been given, 
under the fear that it would purge too much. His patient now had invo- 
luntary discharges of greenish water, wild delirium, dilated pupils, a vacant 
stare, sharpened features, and great restlessness ; the surface of his trunk and 
head was rather warm, that of his extremities too cool ; his thirst was 
urgent, his tongue dry, rough, and red, his abdomen swollen and tender, 
and his pulse 140 in a minute, small and undulating. Blisters to the ankles, 
mustard to the feet, and hot stones were immediately ordered*; and at the 
same time a stream of warm water was directed upon the abdomen and con- 
tinued uninterruptedly for three hours, at the end of which time the feet had 
become irritated and warmed, the circulation was equalized and the patient 
fell asleep. Hot bran poultices were then applied to the abdomen for 
four hours, and after that a blister. During the two latter applications a 
stream of cold water was directed upon the head. Internally small doses 
of Epsom salts, nutmeg, and acetate of lead were ordered.* On the after- 
noon of the next day, 26th, Dr. Gordon found that his patient had passed 
three small discharges of the kind just mentioned; and the delirium con- 
tinued except when the cold applications were made to the head ; but his 
pulse had fallen to 120 and was fuller ; the dilatation of the pupils was 
less • the restlessness also less, and the patient had taken a few short naps. 
Other blisters were now applied to the legs, the same medicines were con- 
tinued, and small portions of nitrate of potash and oil of turpentine were 

* Here was an inevitable decomposition, with the formation of sulphate of lead and acetate of mag- 
nesia, the former of which is held to be inert; the ingredients of this prescription should therefore 
have been alternated, not combined. 



412 THE PRINCIPAL DISEASES OP THE 

directed in addition. On the 27th the patient was still better, and the same 
treatment continued, with the addition of a grain of the sulphate of quinine, 
and half a drachm of spirit of nitrous ether every three hours through the 
forenoon. On the 28th he was much improved in all respects : an occa- 
sional dose of infusion of quassia was added to the treatment. On the 30th 
his appetite was restored, his skin natural, and his alvine discharges 
nearly healthy. On the 5th of April his convalescence was advancing favor- 
ably, on the 12th he was able to sit up, and on the 20th went abroad. 

In reference to the treatment pursued in these two cases, Dr. Gr. remarks 
that it has been uniformly successful in his hands, and that during the 
winter of 1845, '46, he saw more than a dozen cases as violent as the second. 
It is admitted by all the physicians of his neighborhood, that irritating ap- 
plications to the prima3 viae are injurious. Some of his brethren give minute 
doses of calomel and blue mass throughout the whole course of the fever ; 
but he limits their use to the first days. Indeed, in the winter of 1844, '45 
he treated successfully a number of violent cases without any mercurial 
whatever. He places great reliance on minute doses of sulphate of magnesia, 
and acetate of lead, with warm and emollient applications to the abdomen. 

It must be admitted that his method is somewhat outre; but on that 
very account it deserves attention. We have already seen that the ordinary 
and established methods are not attended with any encouraging success, and 
should, therefore, look with interest at any modification of practice which is 
declared to be successful. 



CHAPTER VI 

LOCAL HISTORY OF TYPHOUS FEVERS OF THE SOUTHERN BASIN IN 
ALABAMA AND MISSISSIPPI. 



SECTION I. 

IN NORTH ALABAMA. 

As Tennessee, the fevers of which we have already considered, is sepa- 
rated from Alabama by a conventional line, — the 35th parallel of latitude, 
the southern portions of the former and the northern of the latter make, in 
medical topography and climate, one region, everywhere jutting up against 
the bold escarpments of the Cumberland Mountains on the southeast, also 
on the south, southwest, and west, for a spur of that mountain winds round 
to the north. In this region lies the Great Bend of the Tennessee River, 
embracing most of the district in its ample concavity.* 

* For a sketch of the geology and medical topography of this district, see PI. I. (frontispiece)°of vol. 
i. and pp. 222 to 225. 



INTERIOR VALLEY OF NORTH AMERICA. 413 

SECTION II. 

IN MAURY COUNTY.* 

I. From Dr. Frierson, formerly of Columbia, in this county, but now of 
Memphis, I received the following facts : — 

Several years since, a continued typhous fever commenced, in the month 
of May, in the negro family of Dr. B., who lived a few miles out of Colum- 
bia; and successively attacked all the negroes on his plantation. Dr. Frier- 
son's father resided in the neighborhood, and the two families had constant 
intercourse. In a fortnight from the beginning of the disease in the family 
of the former, it commenced in that of the latter gentleman. A married 
son of Mr. Frierson, who resided three miles from him, visited the family, 
and sat up with the sick as a nurse, took the disease and died. The physi- 
cian and colored nurse, who waited on him, both suffered attacks of the 
same kind. Two other sons, who were at school, ten miles off, visited and 
remained with the family two days. In nine days after returning to school, 
one of them was seized with the fever, and in three days afterwards it at- 
tacked the other. 

I am indebted to Dr. J. T. Sowell, of Athens, for the following notice of 
the typhous fevers of that town and the surrounding country. 

II. In North Alabama, previously to the years 1832 and '33 (when 
epidemic cholera prevailed in the United States), the people and physicians 
scarcely knew of any other form of fever than the autumnal bilious, which 
prevailed much more in some localities than others. Since 1832, it has 
prevailed much less, and within the last few years is scarcely met with. 
As this endemic declined, there arose a tendency to morbid sensibility and 
inflammation of the stomach and bowels, strongly contrasting with the torpor 
and insensibility which those organs had previously displayed. For ten or 
twelve years after this change commenced, almost every form of disease was 
prone to terminate in, or be complicated with, gastro-enteritis. During the 
latter six or eight years febrile affections have assumed a typhous character. 
This change did not take place with sudden and epidemic violence, but in- 
sidiously and imperceptibly. The new modification seemed to approach 
from the west, and made its impress gradually on existing diseases, till 
they were so to speak, transformed into its own likeness, and it became the 
predominant malady. Unlike the endemic periodical fevers, it made its 
attacks irrespective of locality ; and was neither more nor less prevalent, 
nor violent, in the places most or least affected with those fevers. 

Dr. Sowell has not been able to collect any proofs of its contagious pro- 
pagation. It has frequently shown itself in families, who had not been in 

* See yol. i. p. 232, No. XVI. 



414 THE PRINCIPAL DISEASES OP THE 

communication with others affected, certainly for months before, if ever ) 
and often but a single case would occur in a family, though all its members 
waited on the sick. On the whole Dr. Sowell is convinced that it has not 
spread by contagion. Of auxiliary causes he says, that as in former times 
whatever exhausted or perverted the powers of the system, as a debauch, 
wounds, &c, brought on an attack of bilious fever, so now the same or 
like causes bring on an attack of typhous fever. 

III. The onset of this fever is scarcely ever sudden, but slow and 
stealthy. The patient continues for several days to complain of languor, 
listlessness and indisposition to mental as well as bodily effort, accompanied 
with anorexia, and either costiveness or diarrhoea, the former most frequent, 
but in both conditions there is an undefinable sensation of uneasiness in 
the bowels. In the early stages the tongue is coated with a thin white fur 
gradually becoming longer and heavier ; its edges and papillae are red, and its 
anterior portion is compressed laterally, till it assumes a remarkably 
pointed form. This aspect of the tongue is palpably diagnostic of the 
fever. Sometimes, however, the appearance of the organ continues healthy. 
The pulse is accelerated in frequency. With the progress of the fever 
delirium, coma, and subsultus tendinum are common ; diarrhoea not quite 
so frequent. Tenderness in the right iliac region with gurgling under 
pressure is invariable and highly pathognomonic ; as are the great weak- 
ness and obtuse pains in various parts, but most frequently in the legs. 
In some cases the pain and soreness could be traced down the thigh along 
the course of the nerve to the gastrocnemii muscles, the feet and toes. 
In other cases. the pain was along the crest of the ilium or in the sacrum. 
Pain in some one of these regions was present in every case, and regarded 
by Dr. Sowell as characteristic of the fever. In one case paralysis of the 
arm occurred, from which recovery took place. Hemorrhage from the 
bowels sometimes took place ; but petechias and sudamina were not seen. 
During convalescence, all who had been seriously ill, lost their hair, but it 
was soon reproduced. A puffy or bloated aspect often followed the disease, 
accompanied by a feeling of inertness. From the prejudices of the people 
Dr. Sowell could not make any iiost-mortem inspections which he regards as 
worthy of being reported. 

IV. Treatment. — Dr. Sowell's experience has convinced him, that 
medicines are palliative not curative in this fever, and that the disease will 
run its course. When attempts have been made to hurry the cure, injury 
has been the result. Little more could be advantageously done than to 
restrain the bowels when too loose, with a little paregoric or Dover's pow- 
der ; or assist them when too slow with small doses of castor oil, or some 
saline aperient. For the hemorrhage, he found nothing equal to creasote, 
and for tympanitis, oil of turpentine was the best remedy. Counter irri- 
tation was of little value. Cold applications to the head were acceptable, 



INTERIOR VALLEY OF NORTH AMERICA. 415 

and sponging the surface of the body produced quietness. Stimulants, gene- 
rally desired by the patient, were administered with advantage, as they 
contributed to fulfil the great indication, that of sustaining the strength till 
the fever should run its course. 



SECTION III. 



I. This is one of the hill counties of South Alabama, lying between the 
upper waters of the Coosa and Tallapoosa Rivers, a region not described in 
the topographical portion of this work. The surface is hilly, with pine 
forests, and the rocks beneath are calcareous. Its latitude is a little below 
the 34th parallel. Dr. Geo. R. Grant, now of Memphis, Tennessee, resided 
and practised his profession in this county for four years, that is, from 
1840 to '44, during which he met with the subepidemic of which I am 
about to give an account. 

I. Colonel J. removed from Georgia to Benton County in the winter of 
1840-41, bringing with him about seventy negroes. They were lodged in 
log cabins, built on an eminence, with tight floors, and they were sufficiently 
elevated above the ground, and closely chinked and daubed between the 
logs. Each had a door, and on the opposite side a small window, with a 
shutter. Each lodged a family, which sometimes numbered eight or 
ten individuals. A small stream, notorious for the production of autumnal 
fever, meandered near this quarter. On the plantation, in the spring of 
1841, without any evidence or suspicion of introduction, a continued or 
typhous fever broke out, and prevailed till forty-eight cases had occurred, of 
which one-fourth proved fatal. Nearly all the patients were adults under 
forty, of both sexes ; very few children suffered. Before proceeding to 
detail the symptoms, I must give an account of the apparent communication 
of the disease to another family. Mr. A., Colonel JVs overseer, was seized 
with diarrhoea, which as we shall presently see, ushered in the fever ; where- 
upon he left the plantation for his father's house, seven miles off. At 
that time, as far as Dr. Grant knew, the fever prevailed nowhere but on 
Colonel JVs farm, and certainly had not occurred in the family of Mr. A., the 
father. In a fortnight after the overseer reached home, being affected with 
the fever, his brother was seized with the same kind of diarrhoea, followed 
by fever and delirium, which lasted two weeks. During his illness a sister 
was attacked in the same manner, and a few days afterwards another sister, 
all having the initiatory diarrhoea, with subsequent delirium, and continuing 
ill about a fortnight. Further than this the fever did not spread in or from 
this family. "We must now return to a description of the disease. 

II. Symptoms. — The attack was generally gradual, and almost every 
patient had diarrhoea, while he still went about. On this supervened ano- 



416 THE PRINCIPAL DISEASES OP THE 

rexia, dull headache, and great lassitude. There was seldom any chilliness. 
In the second stage, there was a quick, frequent, but easily compressed, 
pulse ; hot skin, and white furred tongue with red edges and tip. Under 
pressure there was, in some cases, epigastric tenderness, but the same con- 
dition, with actual pain, was much more common, in the right iliac fossa. 
A certain degree of remission in the febrile symptoms was perceptible in 
the morning. There was rarely any deep coma. Delirium at length super- 
vened, and in the second week of the fever, was in many cases of a bois- 
terous kind ; sometimes in its character it approached to mania d potu. 
The diarrhoea which ushered in the disease, was prone to continue through- 
out its whole course. The discharges, from the beginning thin and yellowish, 
became at length extremely offensive, and were always rendered more 
watery by cathartics. In the latter stages of the disease, the redness and 
rawness of the tongue increased. In many cases there was subsultus ten- 
dinum. The fever generally terminated in about a fortnight. In a few 
cases there was cough and slight expectoration, but no signs of pulmonary 
engorgement. 

This description, drawn chiefly from the patients on the plantation of 
Colonel J., is applicable to the disease as it appeared on other plantations 
in subsequent years. 

III. Post-mortem appearances. — Case I. In the spring of the year 
1844, a negro, twenty-four years of age, died of the characteristic symp- 
toms, including of course diarrhoea. He also had cough, which was not 
present in every case. He had taken great doses of calomel, under which 
he had profuse and exhausting alvine discharges. His brain was not ex- 
amined. The lungs and heart were sound; as were the stomach, liver, and 
gall-bladder. The spleen was enlarged and softened, though the patient 
was not known to have had intermittent fever. Many of the glands of 
Peyer and Brunner were inflamed and ulcerated; and the intervening 
mucous membrane was in a state of hyperemia. The colon presented very 
little ulceration. 

Case II. A mulatto girl, aged fifteen, on the same plantation with the 
last, died at the end of the fourth week. She had experienced but little 
delirium, and at one time seemed to be convalescent. Had been treated 
with gentle evacuants, and the sulphate of quinine. The brain was not 
examined. The thoracic viscera were healthy; and so were the stomach, 
liver, and gall-bladder, which was distended with yellow bile. The spleen 
was tumefied and tender, notwithstanding she had never had an attack of 
autumnal fever. The mucous membrane of the entire ileum was inflamed, 
and presented many large spots of ulceration, not confined to the elliptical 
patches. The colon was normal. 

IV. Treatment. — In a few cases Dr. Grant employed the lancet, but 
to no good effect. Local bleeding did better, especially when there was any 
pulmonary affection, for which likewise he blistered. He gave no emetics, 



INTERIOR VALLEY OF NORTH AMERICA. 417 

and used purgatives very sparingly, for in fact purging always seemed in- 
jurious. The physician who treated the first cases on the plantation of 
Col. J., gave large doses of calomel, and every patient died with hemorrhage 
from the bowels. Dr. Gr. himself was induced to try drachm doses of that 
medicine, for which he hopes to be forgiven, under a resolution never again 
to resort to a practice so mischievous. He administered calomel, however, 
in minute portions, with Dover's powder, and saw benefit from the practice. 
He also gave small doses of acetate or sulphate of morphine in acidulated 
gum-water, with some good effects. The oil of turpentine administered in 
the same vehicle, in a few cases seemed beneficial. The sulphate of quinine 
did no good. When a crisis was at hand, he found wine of service ; but on 
the whole, he found it best to moderate particular symptoms, and leave the 
cure to nature. 

V. In reference to this epidemic Dr. Clarke says : " In August, Septem- 
ber, and October of 1840, in Benton County, a typhoid fever prevailed as 
an epidemic, assuming frequently a malignant, obstinate, and unmanageable 
character. It attacked, indiscriminately, individuals of all ages, without 
regard to sex or color. During the prevalence of this fever, we had also 
every grade and variety of intermittent and remittent, throughout the sum- 
mer months, but all the fatal cases were of a typhoid character." 

" The fever — typhoid — was not ushered in by any distinct chill, but was 
some days in forming, and crept slowly on the patient. They grew dull ; 
complained of being unwell, ' and weak j' the skin became dry and harsh; 
there was anorexia, headache, stupidity, and sleeplessness; there was at 
first some degree of constipation, subsequently diarrhoea; finally, more or 
less fever was developed, the pulse becoming accelerated, but always com- 
pressible, in some cases from 75 to 90, in others from 100 to 120. The 
skin usually became hot, especially about the head and across the abdo- 
men ; in some there was a tendency to coldness of the feet, which was diffi- 
cult to remove ; in others the feet, like the rest of the surface, became hot. 
The tongue by degrees assumed a redness on the edge, and in some bad 
cases was dry and fissured, there was dryness of the mouth, and constant 
calls for water. 

" One marked symptom usually prevails in every case, viz., intense pul- 
sation of the carotids ; the alvine evacuations frequently change as to consis- 
tence and color; the abdomen becomes tympanitic, in some cases highly so; 
and after a few nights, insomnolency and delirium. 

" The fever generally lasted from fifteen to twenty-one days, and it was 
from five to six weeks after the patient complained of being unwell, before 
restoration to health." 

The anatomical character of this fever, according to Dr. Clarke, consisted 
of enlargement and softening of the spleen ; a dark leaden appearance of a 
portion of the mucous membrane of the small intestines, with here and 
there thickened, dark, ash-colored spots in the ileum, which were easily 

vol. ii. 27 



418 THE PRINCIPAL DISEASES OF THE 

scraped down. Yery little redness was noticed anywhere in that bowel; 
but on the contrary, it had a pale darkened appearance.* 



SECTION IY. 

FURTHER SOUTH — IN AND AROUND DALLAS COUNTY.f 

This region is greatly infested with periodical or autumnal fever. In his 
paper on the diseases of Alabama,! Dr. Lewis, in speaking of what he calls 
typhoid fever, observes : — 

" The first information that is presented to our notice of its appearance in 
a marked form, was in Dallas County, during the spring of 1835. In this 
instance it was the sequence of typhoid pneumonia that had prevailed during 
the previous winter, assuming at that time an irregular intermittent type. 

" A planter in this county, for the purpose of procuring manure for some 
worn-out lands, had exposed to the weather, several hundred bushels of 
cotton-seed, which during the latter part of December, became completely 
saturated with water ; the heat retained in so large a mass, soon set up very 
active decomposition. Some fifteen or twenty negro houses were situated 
in a circuit immediately around the spot where the seed were exposed. 
About the middle of January, several cases of pneumonia were developed 
among the negroes, which continued occasionally to attack them until the 
month of March. 'The spring opening warm, the disease immediately as- 
sumed a new type, and continued to prevail, until every negro above the 
age of five years had been seized. The attack in these cases was insidious, 
the disease forming very slowly; there was a slight remission every morning 
for five or six days, after which it became continued, with clammy skin, 
quick compressible pulse, diarrhoea, coma, and sordes of the teeth; the 
disease ran its course in from fifteen to twenty-five days ; average mortality 
about twenty per cent. 

" Dr. Pearson mentions a striking instance of a similar character, and as 
such facts when clearly ascertained, cannot fail to assist in the most impor- 
tant of medical inquiries, we will here quote from his esteemed favor. 

" l The past winter, a friend of mine had his gin house burned down, in 
which there is a great deal of cotton-seed and cotton in the seed. This pile 
was burning for weeks. As his stock used this yard, the ground, which 
was prairie, became soft from the treading of the cattle ; there being also a 
good deal of wet weather, it gave rise to a collection of water over the 
charred seed, which became peculiarly offensive both to the eye and olfac- 
tories ; with myself, it produced a paroxysm of sneezing. 

" < It was on the south side of his negro quarter, the inmates of which be- 

* New Orleans Med. and Surg. Jour, for July, 1847, pp. 9 and 33. 

t See vol. i. pp. 184-5, No. III. 

t New Orleans Med. and Surg. Journal, July, 1847, p. 31-2. 



INTERIOR VALLEY OF NORTH AMERICA. 419 

came sick. The first cases were of typhoid and pleuro-pneumonia, and after 
the weather became warm, it assumed the type and character of typhoid fever. 
The members of his family, both black and white, remote from the quarter, 
although not more than two hundred yards distant, but in an easterly 
direction from the contaminated spot, were exempt from the disease. I feel 
certain that this disease had its origin as stated, and strictly local, as the 
entire neighborhood was healthy. There were as many as sixty cases, and 
and all were benefited by quinine/ 

" These and other instances, which we have not space to detail, are sufficient 
to induce the belief that the decomposition of cotton-seed by process of fer- 
mentation, produces a gas, probably the ammoniacal, which affects a majority 
of those who may be subject to its deleterious agency. These effects of 
course will vary with the change of season, and in that revolution the con- 
stitution of the atmosphere induces varied types. 

" We have repeated instances presented to notice where low, dirty build- 
ings become the place of deposit for filth, acted on by moisture, or the 
decaying of the logs with which a large portion of our country houses are 
constructed, becoming the medium of disease. 

" Typhoid fever, as usually presented in this section of the country, is vari- 
able in its character, in many cases attended with grave and malignant 
symptoms, owing in a great measure to locality ; as for instance, in our prai- 
ries and low bottom lands ; whilst on the other hand, there is more vascular 
excitement, and inflammatory action in the hilly region of country. 

" In the former instance, Dr. Hogan, in his letter, says : ' The disease is 
usually ushered in by a chill, not unfrequently a double tertian; the fever 
being remittent, with partial perspiration, great enteric irritation, termina- 
ting in special congestion, with a species of paralysis agitans, or meningitis 
may supervene. There is more or less pulmonary congestion that is pre- 
ceded by cerebral disturbance, sometimes in the form of delirium, and at 
other times it may be attended with stupor, or coma. In brief, typhoid 
fever may invade by the brain, the lungs, or the bowels, and in the grave 
cases, all these organs are apt to be involved, and your patient may die from 
exhaustion, in a physiological condition. 

" ' Whenever a patient is found with a dry, red tongue, excessive tenderness 
of the abdomen, small, fluttering, or wiry pulse, that is easy to be compressed, 
the eye dull, leaden, and watery, morbid condition of the cerebral organs, 
and the bowels easily excited to action, we should not hesitate, under ordi- 
nary circumstances, to pronounce it a case of typhoid fever of the low 
country. 

" ' Typhoid fever prevails in autumn, winter, and spring ; most usually the 
latter; and is met with annually in various sections of our country, either 
sporadic, or prevailing as an epidemic on some particular plantation, attri- 
butable to local causes/ " 



420 THE PRINCIPAL DISEASES OF THE 

SECTION V. 

IN MISSISSIPPI, CARROLL COUNTY.* 

I. History. — Dr. Edward Montgomery has kindly furnished me with 
the materials for this notice, in a letter dated in July, 1846, at which date 
he had resided there between three and four years. Daring that time he 
had treated about forty cases, eight of which proved fatal. They were scat- 
tered through the three years, but occurred chiefly in the summer of 1844, 
when the fever assumed an epidemic character. Cases, however, occurred 
every season, and so often in cold weather, that the inhabitants had given 
it the name of "winter fever," a fact that seems to indicate its occurrence 
in that county previously to Dr. Montgomery's arrival. In 1844, it attacked 
the inhabitants of a part of the county which had been regarded as the 
most healthy, and was limited to about three square miles. It affected 
whites more than blacks ; the delicate and the robust were equally liable ; 
of whites, those between fifteen and thirty ; of blacks, those between eight 
and fourteen, were most liable. Most of the subjects were natives of the 
South, but not all of that county, which had not been settled more than 
fifteen years. He often saw a single case only in a family, but sometimes 
three. The duration of the fever was from eight to twenty-eight days. 
During this visitation, there was another local sub-epidemic twelve miles 
southwest of the one described. He saw a case, and found it to be the same 
fever he was treating. He heard of a planter in that neighborhood, twenty 
of whose negroes had it, of whom four died. 

II. Symptoms. — The fever generally commenced suddenly, with nausea, 
rigors, and pain in the head, back, and loins ; in the reaction, the pulse was 
frequent, and the skin hot and dry, with thirst; the sleep was disturbed, and 
morbid drowsiness and vigilance sometimes alternated with each other ; the 
bowels were generally costive, and the discharges dark-colored and very 
fetid; in a few days the pulse in many patients became extremely frequent 
and intermittent; the tongue was in some dry and brown, in others, moist 
and clammy, often tremulous and protruded with difficulty; active delirium 
was not uncommon ; but sometimes there was great listlessness and indiffe- 
rence ; in the advanced stages, the usual symptoms preceded a fatal termi- 
nation : they were low delirium, subsultus, picking at the bed-clothes, 
sordes on the teeth, and unconscious discharges of faeces and urine. From 
the commencement to the termination, the fever was continued, or marked 
with very slight remissions. No post-mortem inspections were made. 

III. Treatment. — Dr. M. pursued the same treatment he had followed in 
the typhus fevej* of Scotland and Ireland, only " modified to suit the more 
relaxed constitutions of a southern climate." If called early, and the 
patient was robust, he bled once from the arm ; afterwards, or when this 

* See vol. i p. 209, No. III. 



INTERIOR VALLEY OF NORTH AMERICA. 421 

was omitted, he scarified and cupped the cervical and upper dorsal portion 
of the spine, extending the application to the epigastrium when there was 
great nausea or sense of oppression in that region. Having done this, he 
gave an active cathartic of calomel, jalap, antimonial powder, and some 
aromatic. After these evacuations, he relied for a few days on refrigerants 
and other antiphlogistics, as sulphate and bitartrate of potash, sulphate of 
potash, infusion of digitalis, with hyoscyamus, Spiritus Mindereri and effer- 
vescing draughts, with gentle opiates. He also gave more or less of a mix- 
ture of chalk and quicksilver, blue mass, and ipecac, in pills, especially when 
the bowels continued torpid. He depended greatly, however, on the appli- 
cation of cold water over the head and trunk of the body. When the vital 
forces began to fail, he applied a blister to the head and neck, and began 
the administration of sulphate of quinine, brandy, wine-whey, carbonate of 
ammonia, and other stimulants; keeping the head at the same time under 
the influence of cold water. 

The history of this fever seems to mark it as typhus, rather than typhoid. 



SECTION YI. 

EPIDEMIC TYPHOUS FEVER IN NEW MEXICO. 

From the late lamented Dr. Josiah Gregg, author of the " Commerce of 
the Prairies," I received the following notice of a typhous fever in New 
Mexico. 

" During my residence in Santa Fe, a well-marked and very fatal typhus 
fever (as I am now convinced it was) raged through all Northern Mexico. 
It originated in the southern or littoral provinces, about the year 1835, soon 
after the disappearance of the epidemic cholera. It thence gradually made 
its way northwardly, reaching the province of New Mexico in 1837, which 
it ravaged till 1840, when it was superseded, or at least succeeded by small- 
pox. During this period, the mortality was appalling, and, for those healthy 
regions, unprecedented. In a communication which I received from the 
Secretary of State, at Santa Fe, it is estimated that ten per cent, of the 
entire population perished, but this is probably an exaggeration. 

" What appeared remarkable in this disease was, that it seldom attacked 
foreigners (citizens of the United States), and the few who were affected 
did not suffer seriously, — indeed, I never knew a single fatal case among 
them. 

"Although apparently contagious, its propagation seemed almost confined 
to the different members of the families into which it was introduced, visitors 
being but little subject to the infection, if any existed. When it commenced 
in a family, it generally ran through all who composed it, except the 
foreigners who might belong to it. Their exemption, when equally exposed 



422 THE PRINCIPAL DISEASES OP THE 

to the specific remote cause, should be ascribed, I suppose, to national diffe- 
rences of constitution, diet, and modes of living generally." 

[The author had intended here to introduce a note concerning Dr. Gregg, 
which, however, is not to be found. — Ed.] 

[Section VII. is unwritten. A memorandum refers to articles on the Fevers 
of Natchez, in the Western Journal of Medicine, also, to papers in the 
Medical Recorder and American Journal of the Medical Sciences ; mentions 
also typhous fevers at St. Louis and St. Charles, but without references to 
sources of information. — Ed.] 



CHAPTER VII. 

CONTINUED OR TYPHOUS FEVERS OF THE EASTERN OR ST. LAWRENCE 

BASIN. 



SECTION I. 

WITHIN THE UNITED STATES. 

I. That portion of the Basin of the Northern Lakes which belongs to 
the United States, seems not to be as much affected with continued fevers 
as the eastern parts of the Southern Basin, over which we travelled in the 
preceding chapter. At first view, we might expect the more northern region 
to suffer most; but we must remember that a large proportion of the people 
live near the flat shores of the Lakes, or on the estuaries of the rivers which 
enter them, and therefore under very different topographical circumstances 
from those who reside in the dry and ridgy zone which stretches westwardly 
from the Apalachian Mountains in the Southern Basin. Thus the topo- 
graphical neutralize or nullify the climatic conditions. In presenting the 
few meagre notices for which I have been able to collect the requisite facts, 
I begin in the northern part of the Basin. 

II. At Fort Brady, Sault St. Mary.*— 1. In the winter of 1826-7, 
Surgeon Pitcher, now a physician in Detroit, witnessed an epidemic at the 
Sault, which he regarded as the typhous mitior of the nosologists. In 1842, 
he gave me the following account of it. The population of that distant 
spot consisted of the troops in Fort Brady, and of Creole or Canadian French 
living around the Fort, in small, unventilated cabins. Its prominent symp- 
toms were a dry and burning skin, dry tongue, costiveness, slight delirium, 
restlessness, and great debility. In some cases, the blistered surfaces became 
gangrenous. In many instances, it ran on for several weeks. None of the 
troops, but some of the French died. 

* See vol. i. p. 334, No. V. 



INTERIOR VALLEY OF NORTH AMERICA. 423 

Treatment. — This was temporising. Venesection was resorted to in two 
or three cases only. Emetics were not used, and none but the mildest 
cathartics prescribed. The carbonated alkalies, and in some cases, camphor 
and opium were directed with advantage ; but the chief reliance was placed 
on sponging the skin with cold or tepid water. In the latter stages, bark 
and wine were often serviceable. 

Dr. Pitcher assured me that this was the only time he had met with a 
typhous fever in the North. 

2. In the winter of 1837-8, there was a second invasion, of which Sur- 
geon M'Dougall has given the following account : — * 

" Shortly after my arrival at Fort Brady, in October, 1837, scorbutic 
symptoms were manifested in every case of disease which occurred, such as 
spongy gums, with hemorrhage, unusual debility, coldness of the surface, 
and the sensation of sinking in the epigastrium. The whole command being 
put on a strictly antiscorbutic regimen, these symptoms soon disappeared 
without any recurrence. At this period, the first case of typhus was re- 
ported; but as I soon became a subject of the disease myself, I lost the 
only opportunity I have had of observing and treating this formidable dis- 
ease. 

u Symptoms. — Lassitude, loss of muscular power, tinnitus aurium, dispo- 
sition to syncope, pains in the head, back, and extremities ; difficult respi- 
ration; rigors; pulse irregular, small, quick, and sometimes hard; tongue 
clean and red, and bowels constipated. In most cases, within sixty hours 
from the attack, reaction was fully established ; then the tongue became 
dark and dry, with hemorrhagic fissures, the teeth covered with black, tough 
sordes, the eyes red and watery, and the temperature of the skin increased, 
giving that peculiar tingling sensation to the fingers characteristic of the 
malady. If the disease continues, petechial blotches appear, followed by 
subsultus tendinum, delirium, extreme prostration, and death. A favorable 
prognosis is indicated by a gradual subsidence of the symptoms detailed, 
abatement of thirst and heat, moisture of the skin, disappearance of pete- 
chise, black discharges from the bowels, hemorrhage from the nose, deafness, 
and a turbid secretion from the kidneys. 'The duration of the disease was 
from one to two months. 

" The treatment consisted in ventilation of the wards, strict police, and 
personal cleanliness, tepid bathing, and calomel and opium to correct the 
secretions, diffusible stimulants, particularly carb. ammoniae, rubefacients, 
blisters, and occasionally cups applied to the epigastrium. Some of the 
cases were undoubtedly typhus syncopalis, but the general character of the 
disease was that of typhus gravior and mitior. The first case originated 
within the pickets, which are near twenty feet in height ; the next occurred 
among the hospital attendants, then among the convalescents from other 
diseases, until, finally, all in the hospital, excepting the steward, were 

* Med. Stat, of the U. S. Army, 1845, p. 72. 



424 THE PRINCIPAL DISEASES OF THE 

affected. The only case that proved fatal in hospital was a private under 
treatment for gonorrhoea. From the garrison, the disease extended to the 
village, and thence to the Canadian shore. 

" The probable causes of the fever were, the long-continued prevalence 
of northeast winds, with rain, which, in this climate, is remarkably de- 
pressing to the powers of life — great accumulation of vegetable matter in 
a putrid state beneath the buildings of the fort, and in its immediate 
vicinity, confined air from the high stockade, and deficiency of acetic vege- 
tables." 

As this is the most northern post of the United States, I may mention 
that the Army Statistics, exclusive of the cases occurring in this subepi- 
demic, give but seven cases of typhus in ten years.* 

III. At Milwaukie. — When at Milwaukie, in 1844, I learned from 
Dr. Bean and Dr. Bartlet, that while they seldom have autumnal fever, 
either intermittent or remittent, a fever of a continued type is not uncom- 
mon. It prevails most in November and December. 

Symptoms. — Its forming stage is generally protracted through one or 
two weeks. When established the pulse is full and frequent — sometimes 
tense, at other times quite compressible. Slight morning remissions are 
not uncommon. The stomach is often irritable, with retchings, and the 
bowels inclined to constipation; though diarrhoea occasionally occurs in the 
latter stages. In the beginning the tongue is covered with a yellowish fur, 
which becomes dry and brown, and in the progress of the fever, sordes col- 
lect on the fore teeth and lips. The eyes often become suffused. Mild 
delirium, subsultus tendinum, and coma occasionally occur. The duration 
of the disease is from two to four weeks. Affects the young more than 
aged. 

Treatment. — Dr. Bartlet resorts to the lancet in a few cases. Purges 
with calomel and rhubarb, sometimes quickening their action with Epsom 
salts, till bilious stools are produced. Then resorts to diluents and diapho- 
retics, one of which is a watery solution of ipecac. To the head, he makes 
cold, and to the feet and epigastrium, warm applications. He has not seen 
beneficial effects from the sulphate of quinine. 

Dr. Bean employs bloodletting and purging to a greater extent than Dr. 
Bartlet. The latter he effects in part with calomel, but does not administer 
that medicine with a view to its constitutional effects. After alvine evacu- 
ation he tranquillizes his patient with Dover's powder. In all other respects 
their practice is the same. 

I may here state that in the towns of Michigan, Chicago, Racine, and 
Navarino, on the southern and western coasts of Lake Michigan, I was 
assured that typhous fevers were almost unknown. 

TV. In the Interior oe Michigan. — In returning from Milwaukie, 
inquiries on the island of Mackinac, at Port Huron, and Fort Gratiot, lower 

* Med. Stat, of the U. S. Army, 1845, p. 73. 



INTERIOR VALLEY OF NORTH AMERICA. 425 

end of Lake Huron, and at Detroit, informed me that typhous fevers are 
nearly unknown at the first, very rare at the second, and never epidemic at 
the third. 

V. Coasts of Lake Erie exempt.* — From Detroit to Buffalo, I visited 
nearly every coast town, of which the most populous are Toledo, Sandusky 
City, Cleveland, and Erie, and also many others lying at various distances 
from the Lake up to eighty miles, but never met with a physician who had 
seen even a subtyphous epidemic in that region. Occasional cases of pneu- 
monia, accompanied in the latter stages with low delirium, coma, subsultus, 
and dry red tongue, were the nearest approach to typhous fever they had 
seen. Many physicians assured me they had not met, in years of residence 
there, with a single case of true typhous fever, yet all had occasionally seen 
the supervention of typhous symptoms on the ordinary autumnal remittent 
fever of that portion of the country. We may contrast this exemption with 
the severe epidemic visitations of the country fifty miles south of the Lake, 
and elevated about six hundred feet above it. In Buffalo,f where Dr. 
Trowbridge had resided thirty-seven years, I was assured by him there had 
never been a typhous epidemic, except the pneumonia typhodes of 1812-13 
already referred to. 

VI. Southern Basin of Lake Ontario. — This lake has the mean lati- 
tude of the four upper lakes, Erie, Huron, Michigan, and Superior, but a 
depression below their average elevation of 350 feet j I have therefore made 
it the subject of a separate section, that we may the better estimate the in- 
fluence of altitude on the fevers we are now studying. "We first examine 
the region on the southern side of the Lake, from the mouth of the Niagara 
River, to the head of the St. Lawrence.? 

VII. In the basin of Genesee River,§ I could not hear of a single epi- 
demic or subepidemic typhous, except that of 1813 (Chapter I. Sect. II.). 
From Rochester through Avon, Genesee, and Mount Morris up to Pike, I 
found evidence that in the latter part of autumn remittent fever tends to a 
continued type, and before death puts on the livery of a typhous affection. 
In the winter moreover it is not uncommon to see the same phenomena, in 
combination with original pneumonia. In some autumns and winters, these 
typhous proclivities are greater than others, so great indeed as to approach 
an epidemic prevalence. 

VIII. The basin of Oswego River, which includes most of the beautiful 
little lakes of Western New York,|| is not more affected with the fevers we 
are now inquiring after, than the basin of the Genesee. In Geneva, 
Auburn, Syracuse, and Oswego, I could not learn of a single epidemic 
typhous visitation ; but the general fact was recognized, that the remittent 
autumnal fever which in early times so severely scourged the first settlers, 
had in latter years assumed more of a continued and typhous character. 

* See vol. i. pp. 358, 382. f Ibid. p. 380, No. I. $ IWd. pp. 392-406. 

g Ibid. 394. || Ibid. pp. 400-405. 



426 THE PRINCIPAL DISEASES OF THE 

At one spot only did I hear of a subepidemic typhous fever, concerning 
which I collected the following facts. 

IX. The township of Manlius lies ten miles southeast of Syracuse, where 
the sources of Onondago Creek interlock with those of certain branches of 
the Mohawk and the Susquehanna. This indicates much elevation. In 
the direction of Lake Oneida the surface is low and more or less marshy, 
and infested with autumnal fever. In 1847, Dr. Nims informed me, that 
for some time a typhous fever had prevailed among the inhabitants of the 
hill country, but did not affect those of the plain. In 1846 it commenced 
in July, and prevailed till winter. Its duration was sometimes protracted 
to seven weeks : when fatal it generally terminated in three. There was 
generally more than one case in every family which it invaded. About 
one-third of the cases proved fatal. The majority of its subjects were adults. 
Its type was continued, with a frequent, but not hard pulse; the stomach 
was not often irritable ; but the bowels were affected with diarrhoea, and in 
some' cases there were pain, tenderness under pressure, and tympanitis. 
Many cases showed a hemorrhagic tendency, by discharges from the bowels, 
and petechioe. In a majority of his patients, there was delirium with sub- 
sultus tendinum. The state of the pulse prevented a resort to venesection, 
but he employing cupping in several instances; the quiet state of the 
stomach kept him from prescribing emetics. The blue pill, castor oil, and 
mucilages proved useful. When tympanitis supervened, he administered 
oil of turpentine, or balsam of copaiva, with benefit. In a few cases small 
doses of sulphate of quinine seemed beneficial. Mustard poultices to the 
abdomen, and subsequent warm fomentations, relieved the abdominal symp- 
toms. During an attack of this fever, a child had cancrum oris, and lost 
a part of the teeth and alveolar processes of the upper jaw. 



SECTION II. 

IN THE CAN AD AS. 

I. I cannot speak with as much confidence of the northern as the 
southern sides of the basin of Lake Ontario and Lake Erie, but the few 
places which I visited, and the letters which I have received from others, 
have not made me acquainted with a single typhous epidemic ; though they 
indicate a typhous termination of autumnal fever, which in that high lati- 
tude is prone to assume a continued type. 

On this subject Dr. Stratton* has published the results of his observations, 
on the fevers of that region, — the western portion of Upper Canada. The 
phrase which he employs is " malarial continued fever." The disease 
generally begins with debility, impaired appetite, slight headache, irrita- 
bility of temper, or some unusual mental state. These symptoms increasing, 

* Edin. Med. and Surg. Jour. vol. lxiy. p. 105, and lxvi. p. 74. 



INTERIOR VALLEY OF NORTH AMERICA. 427 

in a couple of days the patient confines himself to bed. Reaction comes on 
with an aggravation of all the symptoms, and the addition of morbid heat, 
thirst, loathing of food, a bad taste in the mouth, extreme languor, intole- 
rance of sound, light, and society, slight delirium, mostly at night, sleep- 
lessness, and afterwards drowsiness. The pulse is weak and quick, the 
bowels costive, sometimes there is a greenish or yellowish fluid thrown up 
by vomiting. In some cases there is pain in the region of the liver or other 
parts of the abdomen ; sometimes in the chest with slight cough. In many 
cases the head symptoms are mild; but in some, there is ardent heat of the 
skin, intense headache, followed by drowsiness, sopor, coma; and the 
degree of intensity of disease ranges, by insensible gradation, from that of 
mild common continued fever, to that of typhous gravior." Those who re- 
cover sometimes have impaired vision or hearing for several weeks ; and 
others remain almost stupid for months. This fever may terminate in ten, 
twenty, or thirty days. A majority of the cases end in a remittent or an 
intermittent type. Commonly quotidian, sometimes tertian. When the 
termination was fatal, the chief morbid appearances were " effusion on the 
surface or within the ventricles of the brain." 

The fever generally commences in a sporadic manner in May, acquires its 
maximum of intensity and prevalence in August, and is arrested by the 
frosts of October. 

The lancet is employed in this fever only when the head symptoms are 
intense, but cupping is often resorted to. Dr. S. generally begins the treat- 
ment with an emetic. He gives cathartics or laxatives almost daily; and 
half a grain of tartar emetic three times a day, as long as the powers of the 
system do not flag. Spontaneous vomiting he checks with opium, and a 
sinapism to the epigastrium. Local pains are relieved by blistering. After 
twenty or twenty-five days, he gives a small quantity of wine, five or six 
times a day, and after the disease has existed ten or fifteen days longer, he 
gives small doses of sulphate of quinine, and when it takes on a distinctly 
periodical character, large doses. Throughout the whole course of the fever, 
he makes a liberal use of cold water externally, especially to the head, and 
internally, ice and acids. Sporadic cases of this kind of fever occur 
over all the higher and cooler portions of the Southern or Mexican basin. 
They have been already referred to as common in the Apalachian Moun- 
tains, where elevation compensates for latitude. They are compounded of 
periodical autumnal and continued typhous elements, and mark the expiring 
limits of the former. 

II. In Montreal.* — My information concerning the typhous fevers of 
this city, was chiefly obtained from Drs. Hall, Holmes, and Badgely, espe- 
cially the first. According to these gentlemen, they have a continued fever, 
answering to the synochus of Cullen, which attacks both natives and stran- 
gers. They regard it as a fever of acclimation, and Dr. Hall estimates that 

* See vol. i. p. 418-19, Nos. I. and IT. 



428 THE PRINCIPAL DISEASES OP THE 

eight out of ten strangers suffer an attack, which, however, may not happen 
for several months after their arrival. It has a mild inflammatory cha- 
racter ; but when protracted assumes a typhous aspect. It generally ter- 
minates in two, but sometimes extends through four weeks. In its progress 
Dr. Holmes has seen it assume a remittent type. Beginning in a family 
it is apt to attack all the members in succession. Its onset is insidious. 
General malaise, chilliness, lassitude, and frequently diarrhoea, characterize 
the first stage. The reaction is accompanied by heat, thirst, and backache. 
The tongue, at first moist and white, with red edges, ultimately becomes 
brown and dry. In many cases, there is high excitement of the brain, with 
severe headache; in others the visceral complications are in the chest or 
abdomen. As the tongue changes in color, hemorrhage from the bowels 
and petechia sometimes occur. In visiting the General Hospital with Dr. 
Hall, on the 1st of September, I saw many cases of this fever. They were 
registered as " typhous." Nearly all had irritable bowels, and soft frequent 
pulse; some had furred tongue with red margins; some were slightly coma- 
tose, and a smaller number had mild delirium. They were chiefly Irish, 
but not recent immigrants, for such were not admitted into the hospital. 

It is obvious, I think, that this fever is the equivalent of the remitting 
autumnal fever of our more southern climates; at the same time its affinities 
with typhus cannot be denied. Indeed, I have long been accustomed to 
see sporadic cases answering to a fuller description of this fever, and always 
regarded them as identical with sporadic " typhus ;" though in the early 
stages they might wear an aspect of a different kind. 

But cases occur at Montreal which all concur in denominating " typhus." 
I am indebted to Dr. Hall for returns of the General Hospital for twelve 
years, which show the relative number of patients recorded as having 
"synochus" or " typhus." The former amount to 1502, the latter to 616, 
an annual average of 125 and 54, or more than two cases of " synochus" 
to one of " typhus." The same returns show the relative prevalence of the 
two fevers in the different seasons, the hospital year commencing with the 
1st of May. From that date to the end of October, 894 cases of " syno- 
chus," and 415 of " typhus," were admitted. From the 1st of November 
to the end of April, 608 of the former and 231 of the latter. Still 
further, each has its maximum of prevalence in the same three months, 
August, September, and October, which was 474 for one, and 239 for the 
other. In all this, these fevers follow the law of the autumnal fever of 
lower latitudes; and as they do not differ as much in their symptoms and 
required treatment as the intermittents and remittents of those latitudes 
differ from each other, while we assign them to the same cause, I see no 
objection to ascribing the " synochus" and " typhus" of Montreal to a com- 
mon cause. 

These Montreal fevers, moreover, like the autumnal fever further south, 
prevail both sporadically and epidemically. Thus, for half the years of the 



INTERIOR VALLEY OF NORTH AMERICA. 429 

table, the whole number of cases was 508; for the other half, 1640. The 
smallest number was 65, the greatest, 396, or six times as many ; an in- 
crease quite sufficient to stamp the latter with an epidemic character. 

On the pathological anatomy of the Montreal fevers, I could not collect 
any information ; but am able to give an outline of their treatment. Dr. 
Hall has rarely employed the lancet, but often resorted to the scarificator and 
cups. He sometimes administers a dose of castor oil as the first medicine ; 
in other cases gives an emetic, followed by ten grains of calomel, succeeded 
by a saline cathartic. Afterwards, he administers calomel and antimonial 
powder in alterative doses, alternated with the saline mixture, holding 
nitrate of potash and tartarized antimony in solution. Dr. Holmes bleeds 
occasionally when the head is much affected, and frequently cups. Gene- 
rally gives an emetic before any other medicine, then a cathartic ; after- 
wards calomel and tartar emetic, alternated with spirit of nitrous ether. 
Both gentlemen sponge the surface of the body with cold water, and blister 
to relieve local affections. When the strength begins to fail, Dr. Holmes 
administers opium and camphor, with calomel, and sometimes resorts to 
assafoetida and wine. 

III. In Trois Rivieres.* — Dr. Gilmore writes me as follows : " Endemic 
continued fevers occur in some seasons, frequently prevailing from autumn 
till the ensuing summer. They are most rife in close and crowded houses. 
They are apt to spread through the whole family of children, and often 
attack adults also. They are evidently contagious. The chief inflamma- 
tory complications are in the lungs. The best treatment is the antiphlo- 
gistic. The mortality is commonly about five or six per cent." 

IV. In Quebec. f — I was assured by Dr. Morrin that typhous fevers are 
almost unknown in this city, those brought by immigrants excepted. In 
every month of the year, but especially the hot, there are sporadic cases of 
continued fever, which may or may not assume a typhous character. But 
an indigenous typhous fever has never prevailed as an epidemic. Even in 
the old lower town, where the streets are narrow, and the small houses 
nearly destitute of yards, while they are crowded with poor people, no fever 
of the kind has ever prevailed. The late respectable Dr. Racy, and the 
late venerable Dr. Parant made the same statements. 

V. The notices which make up this section are so brief and barren as to 
suggest that Canada is less infested with typhous fevers than the more 
southern regions. But this cannot be true if we regard all continued fevers 
as belonging to the typhous group; for the British Army Reports, after 
presenting a small per cent, of "typhus" and " synochus," show a very 
high per cent, of what is designated as "common continued fever." Some 
of the cases under this head are perhaps mere ephemera, others phlegmasiae 
obscurely developed, and others autumnal remittent fever, assuming a 
continued type, as that fever is apt to do on the northern border of its 

* See vol. i. p. 428, No. VII. t Ibid. p. 424, No. I. 



430 THE PRINCIPAL DISEASES OF THE 

geographical range. After making these deductions, the remainder, pars 
magna, can be nothing else than synochus, which thus far we have classed 
with typhus. This " common continued fever" is far more prevalent in 
Lower than Upper Canada, and constitutes a sort of equivalent for the 
remittent fever, which, as we have seen, prevails much more in the latter 
than the former. 



CHAPTER VIII. 

IRISH-IMMIGRANT FEVER. 

I. Thus far we have treated of continued or typhous fevers as indigenous 
diseases, occurring sporadically, and sometimes becoming epidemic or sub- 
epidemic. If they have in certain instances appeared to spread by conta- 
gion, they have not been traced up to a foreign source ; and have, therefore, 
like our periodical fevers, been regarded as endemics of the Valley. We 
have, however, a typhous fever of foreign origin, introduced by immigrants, 
attacking them in some instances several weeks or months after their arrival, 
and not unfrequently extending from them to the native inhabitants. 
As this modification of typhous may become naturalized among us, it is 
proper to say something of it. To avoid all theoretical expressions, I have 
called it by the name prefixed to this section ; the propriety of which will 
seem less questionable when it is stated that the fever is introduced almost 
exclusively by immigrants from Ireland; by the St. Lawrence, the Erie 
Canal, and the Mississippi River, chiefly the first.* 

The late venerable Dr. Joseph Parant, Physician of the Port of Quebec, 
informed me that the continued fever of the immigrants began about the 
year 1820 or '21; but had been much more prevalent among them since 
1832. 

II. Dr. Douglas has given the statistics of the fever since that time, in a 
tabular statement of the number of immigrants, and the number of patients 
admitted into the quarantine hospital, from 1833 to 1847, inclusive — fifteen 
years. In every year, dysentery or some bowel affection had been compli- 
cated with the fever. 

The average annual number of immigrants for fourteen years, before 
1847, was 23,384, of which 291 were, on an average, received into the 
hospital for the diseases just mentioned. In 1847, or the fifteenth year of 
the table, the number of arrivals was 98,106, the number of admissions for 

* In the month of August, 1847, 1 visited many of the towns and cities on the St. Lawrence, down 
to Grosse Isle, the quarantine station below Quebec, and saw much of this fever, then more extensively 
and fatally prevalent than it had ever been before. From the notes made at that time, and from the 
papers of Dr. G. M. Douglas, superintendent of the quarantine establishment, and Prof. Badgley and 
others of Montreal, contained in the third and fourth volumes of the British American Journal, the notice 
I am about to give, will be formed. 



INTERIOR VALLEY OF NORTH AMERICA. 431 

the same diseases, 8574. The average of admissions for fourteen years, was 
1-2 per cent., that for 1847 was 8-74 per cent. Thus we find that the ex- 
traordinary fever-sickness of 1847 was not owing merely to the great in- 
crease of immigration in that year — more than four times beyond the annual 
average — but to an uncommon or epidemic prevalence of the disease, which 
was proportionally more than seven times as great as the previous average. 
As there was nothing remarkable in the climate of the Atlantic Ocean that 
year, we cannot explain the increase of sickness, but by a reference to the 
sad condition of the lower classes in Ireland at that time, which at once 
prompted to extraordinary emigration, and gave impetus to the prevalence 
of a fever which, as we shall hereafter see, was never absent from that 
ill-fated country. The relative number of the two sexes among the immi- 
grants, is not given ; but of those admitted into the Hospital, the men were 
to the women as four to three, and children were to the former as about 
five to seven, — to the latter, as eight to nine. Of the men, about thirty- 
eight per cent, died, of the women, about thirty-five, of the children, about 
thirty-nine. Thus, it appears that the disease was most fatal in children, 
and least fatal in women. At the Immigrant Hospital, in Montreal, the 
mortality was thirty-three per cent.* On an average, it was about twice 
as mortal as it has usually been in the hospitals of Dublin ; a difference 
not greater than the difference of circumstances under which the patients 
were necessarily placed in the ships which brought them over, and in the 
temporary sheds to which they were of necessity consigned at the quaran- 
tine ground. 

III. Every ship which arrived presented cases of the fever among the 
seamen and officers, who were oftener than otherwise attacked after reaching 
port. 

The physicians, students, apothecaries, clergymen, nurses, and all other 
attendants on the island, amounted to 328, of whom no less than 184, or 
more than half, contracted the fever, which proved fatal to 45, or about 25 
per ceDt. In the Marine Hospital at Quebec, every old nurse, as I was 
assured by Dr. Morrin, experienced an attack. This extension of the dis- 
ease to others than the immigrants, was generally admitted as evidence of 
its contagiousness. It is so regarded by Dr. Douglas, and also by Professor 
Badgley, who has, moreover, mentioned several specific examples of the 
fever having been contracted by visiting ships and sheds. Without denying 
the existence of contagion, I cannot admit that any of these facts are legi- 
timate proofs of its presence ) for if the cause of a typhous fever can be 
generated by famine, crowding, and filthiness of person, clothing, and bed- 
ding it may act on the systems of those who, living in a better condition, 
expose themselves to the contaminated atmosphere, even more certainly 
than upon those who had, as it were, become gradually inured to it. 

Now all who went on board the ships, or into the hospital-sheds, were 

* Brit. Amer. Jour. vol. iii. p. 261. 



432 THE PRINCIPAL DISEASES OF THE 

immersed in an idio-miasmatic atmosphere not less than a contagious one, 
if the latter existed ; for the patients in the sheds were unavoidably crowded 
together, and, in general, when I passed through them, seemed to be lying 
in the very clothes they had worn across the sea. The same gentleman in- 
forms us that a female immigrant introduced the disease into a family by 
calliDg on one of its members, but as she did not labor under the disease 
herself, it must have been an exhalation from her clothing which did the 
mischief, and who could say whether the agent previously imbibed, and then 
given out was contagion or a miasm. But while I object to this mode of 
settling the question, I must state that facts of a different kind show con- 
clusively that cases of the fever were propagated by contagion. Thus I 
was assured at various places on the St. Lawrence, that immigrants had 
communicated the disease to individuals in the country, and they had given 
it to others who waited upon them; in which latter case it would be nothing 
but contagion which did the mischief. 

In Montreal, I was assured by Drs. Holmes, M'Cullough, and Hall, that 
the fever had spread among the poor people of that city from boarding- 
houses in which immigrants had sickened, and whence they had been re- 
moved to the hospital-sheds ; and Dr. Badgley mentions the case of a wife, 
who contracted the fever from nursing her husband, who had caught the 
disease in the sheds. But a more conclusive observation has been com- 
municated to me by Dr. Gilbert. The town of Hatley, in the eastern 
townships of Lower Canada,* lies nearly one hundred miles from the St. 
Lawrence, in an elevated and healthy region. Continued fever is so rare, 
that in five years practice, over a district containing 5,000 inhabitants, 
Dr. Gilbert had seen only five sporadic cases. In the month of July, 1847, 
two men visited Montreal, and were led by curiosity into the sheds of the 
Irish immigrants confined with the fever. Immediately after their return 
home, they were both taken down with the fever; and during the next two 
months, Dr. Gilbert had sixteen cases which could be distinctly traced, 
directly or indirectly, to these two ; for they occurred, in every instance, in 
persons who had watched all night with those sick with the fever. In the 
month of October, another citizen of Hatley visited Montreal, and exposed 
himself to the atmosphere of the sick. Immediately after reaching home, 
he was taken down with the fever, and to him Dr. Gilbert was able after- 
wards to trace up six cases. The fever subsequently spread over the 
country; and Dr. Gilbert saw six patients in an adjoining township, in con- 
sultation, and recognized their fever as the same which had affected those 
who contracted the disease in Montreal. 

Although contagious propagation is thus established, the general history 
of this exotic epidemic clearly indicates, that the contagion was neither 
abundant nor virulent. Thus Dr. Douglas admits that, when cleanliness 
and ventilation were duly attended to, and there was but a single patient 

* See vol. i. p. 421-22, Nos. III. and IV. 



INTERIOR VALLEY OP NORTH AMERICA. 433 

in a room, the fever was generally incapable of communicating itself by- 
contagion. He had known but a single case generated under such circum- 
stances. And, in Montreal, the Rev. Mr. Bancroft knew of three men, 
belonging to different families, who contracted the fever by going among 
the immigrants, but did not communicate it to their friends, or nurses, 
although it proved fatal to two of them. One of the three had ten chil- 
dren, and lay in their midst j but none of them sickened. Prof. Holmes 
assured me that such cases were numerous ; but he believed they were 
limited to families who lived in comfortable circumstances; and in this 
statement, Drs. M'Cullough, Hall, and Badgley concurred. Finally, 
almost every town and village on either bank of the St. Lawrence, had sick 
immigrants in it, and an energetic contagion could scarcely have failed to 
produce a general prevalence of the fever among the resident population, 
which however did not happen. These observations, I think, express the 
experience of the towns along the Erie Canal and the Mississippi River, 
not less than the St. Lawrence ; and encourage us to hope, that the native 
population of our Valley will not suffer to any serious degree by this 
modification of continued fever. 

IV. Symptomatic Characters. — As an introduction to the symptoma- 
tology of this fever, we may recognize two important facts. First. The 
patients 'generally were the poorer, most of them the very poorest of the 
people of Ireland. Persons who had been born and reared in the midst of 
filth ; lodged in un ventilated hovels, imperfectly warmed in autumn, winter, 
and spring; inadequately clothed, and insufficiently nourished. Many of 
them, moreover, had been given to alcoholic intemperance. Second. In 
the years 1846 and 1847 they had been subjected to a famine, under which 
multitudes of the people of Ireland had perished, and from which those 
who escaped to Canada had suffered severely. Their appearance at G-rosse 
Isle, Quebec, and Montreal, was in general emaciated, feeble, haggard, 
and forlorn. Men and women of stout frame had often lost all energy of 
expression, and many children had the physiognomy of lean and anxious old 
age. A fever in such subjects must necessarily differ widely in many of its 
phenomena from the same disease occurring in the native, well fed, clothed, 
and lodged population of the Interior Valley. In such a population, the 
diagnostic signs of fever can never be obscure ; but this was not the case 
among the Irish immigrants. Famine alone produces a morbid diathesis ; 
and the fever hospital sheds of the St. Lawrence presented inmates, whose 
pathological conditions ranged from that diathesis to the most malignant 
typhus — all, however, designated as fever. In every shed which I visited, 
from Oswego on Lake Ontario to G-rosse Isle, I saw patients in bed, who 
scarcely presented a single characteristic symptom of typhous, or any other 
form of fever, yet I was assured that many such sunk and expired. Since my 
visit, I have expected to see a full natural history of the symptoms of this 
fever, from some of the able and indefatigable physicians, who courageously 

vol. ii. 28 



434 THE PRINCIPAL DISEASES OP THE 

grappled with it; but their publications have taken a different direction ; 
and I am thrown back on the brief notice of the symptoms, which partly 
from rapid observation and partly from conversation with a large number 
of physicians, I compiled and published in the journals. at that time. 

" Most of the cases are not seen in the beginning by physicians, and no 
reliable accounts can be got of them; but on the whole, the majority seem 
to sicken gradually ; and in reference to those who had been greatly reduced 
by famine, this is perhaps always the case. There are, however, many ex- 
amples of sudden and violent invasion, followed by a malignant develop- 
ment, and death in a few days. In no instance does the chill become very 
intense, though it may be protracted, nor is the arterial reaction very high. 
In some cases the latter, in fact, never manifests itself — the vital forces 
being inadequate to a rally. The pulse is never tense, and in the highest 
reaction always easily compressible ; its frequency is increased, but not to a 
remarkable degree ; it often becomes almost imperceptible in those who 
recover. From the beginning, the primae vias are more or less, but variously 
disordered. In some there is nausea and vomiting; in all, loss of appetite, 
with thirst. Some are costive in the forming stage, and even throughout 
the fever; in others there is a precursory diarrhoea; in the majority, a 
supervening diarrhoea or actual dysentery. I could not ascertain that there 
is generally a superabundant excretion of bile. The tongue at the onset is 
always covered with white fur, through which the red papillse sometimes 
show themselves ; in a part, the edges and tip of the organ show some un- 
natural redness, but in the greater number the natural color is not exalted, 
but even reduced, so that the white fur seems to shoot out of a pallid mem- 
brane. At the same time the organ becomes broader and flatter, loses its 
elasticity, and receives indentations from the teeth, on which I seldom saw 
any sordes. Its moisture continues in a remarkable degree; it may be 
reduced, but not to the point of dryness; and the whiteness of the fur 
endures to a period equally late. The dry, contracted, mahogany tongue 
of genuine typhus often appears, it is true ; but in numerous instances the 
moist and pale state of the organ continues up to the time of dissolution. 
The usual inequality of heat between the upper and lower parts of the body 
is common. I saw many patients in which the latter were cold, and some 
in which the former were decidedly hot; but great development of caloric is 
not, I think, a constant phenomenon. Delirium is more prevalent than 
coma ; many patients during the night, when it is greatest, are restless and 
even locomotive, becoming the next day composed and of sound mind. 
Somnolency did not appear to me to be a conspicuous symptom. Headache 
is often present. Of the red and dull eye, I saw much less than I had ex- 
pected. A circumscribed flush of the cheek is frequent, but not universal. 
A bilious tinge of the visage occasionally shows itself. Subsultus tendinum 
is comparatively rare. I saw many who seemed to be in articulo mortisj 
and yet showed little or none of that symptom. 



INTERIOR VALLEY OF NORTH AMERICA. 435 

"The skin shows various kinds of maculae. In a few, genuine rose- 
colored spots show themselves, but very soon assume a darker color. In 
the majority, the spots are purple from their first appearance, and of every 
size from ordinary petechiae up to diffused ecchymoses, often bearing a close 
resemblance to post-mortem hyperemias. In some cases the spots are hard, 
like whelts, and the seat of a sensation which leads the patient to scratch 
them, whereupon ulcers follow, which occasionally assume a sloughing cha- 
racter. Hemorrhages from the nose are somewhat common, from the bowels 
and skin not quite so frequent ; nevertheless all the medical gentlemen 
have had cases of well-marked purpura hemorrhagica mixed up with the 
fever cases ; and it may be safely affirmed that in these immigrants the 
blood, under the influence of a reduced, or unhealthy diet, has become 
signally deteriorated. 

" When the fever assumes a protracted form, anasarcous infiltrations into 
the cellular tissue of the lower extremities, or the face, frequently take 
place. Suppurations, in addition to those of the skin just mentioned, are 
common. Those about the back and hips may be ascribed to pressure ; but 
others, occurring in glands, must be referred to the fever. Of these organs, 
the parotids suffer oftener than all the rest, and the discharge of pus when 
they suppurate is copious. Such cases generally end well. 

" A supervening bronchial or pulmonary affection is, on the other hand, 
ominous, and as it frequently occurs, may be considered one of the modes 
in which the fever comes to a fatal termination. 

" But of all the secondary affections, that of the bowels is most frequent 
and fatal, though death may not occur for a considerable time after the 
febrile period has expired. This intestinal disorder seems to be a sort of 
mixed up diarrhoea and dysentery, under which the patient loses the origi- 
nal febrile symptoms, and becoming extremely emaciated, gradually sinks. 
In some instances, the affection sets in during the fever ; in others it is ex- 
cited in the period of convalescence by irregularities of diet 3 in all it is an 
ugly, obstinate, and unmanageable addendum. In the months of June and 
July, it was much less frequent than at the present time, when so large a 
proportion of the patients labor under it as almost to constitute it a new aot 
in the melancholy drama. 

"I have mentioned the nocturnal delirium of some patients, indicating an 
exacerbation at night, and may add to this evidence of periodicity that in a 
few cases there has been a diurnal recurrence of the initial chilliness ; the 
general character of the fever, however, is continued. I have spoken of 
cases which prove fatal in three or four days ; they are few in number, and 
the common duration is from two to three weeks, always excepting those 
which merge in diarrhoea or dysentery, when the end is quite indefinite. 

"When death is the consequence of cerebral, pulmonary, hepatic, or intes- 
tinal concentration, the reason of its occurrence is intelligible enough ; but 
the majority do not seem to die from these lesions, and the cause of their 



436 THE PRINCIPAL DISEASES OF THE 

dissolution is, prima : facie, rather obscure. In every ward that I visited, I 
was surprised at the small amount of visible manifestation of dangerous 
disease, and more than once was prompted to say to the medical gentlemen, 
'I can't see why so many of your patients die/ In wards from which 
many corpses were daily carried out, there would be but few who did not 
look at, and after us, put out their moist tongues with facility, and make 
known their wants ; yet many such patients die soon afterwards ; others die 
when the physician has pronounced them convalescent ; others after they 
have risen and dressed themselves, and crawled into the open air. Such 
deaths cannot be regarded as the effect of any particular organic lesion, but 
of a state of exhaustion, or collapse, bearing some resemblance to the third 
stage of yellow fever, or the recurring chill of a malignant intermittent in 
the Southwest, but more, perhaps, to the fatal stage of epidemic cholera." 

It must be borne in mind, that this brief and desultory sketch is not a 
history of the fever as it appeared in the people of Canada, but in the immi- 
grants. Of the modification which it underwent in the well-fed and vigor- 
ous population of the Colony, I am not prepared to speak. 

Dr. Douglas had an attack of the fever in 1836, and although exposed 
every subsequent year up to 1847, had escaped a second ; but when he had 
been exposed to the concentrated foul air of ships, or crowded hospital 
sheds, and the weather was calm and sultry, he suffered from " derange- 
ment of the bowels, lassitude, and nausea." On the whole, he thinks an 
attack of the fever appears to bestow an immunity for several years. Prof. 
Badgley, however, controverts this conclusion, and affirms that relapses and 
second attacks at more distant periods are common. 

V. Pathological Anatomy. — Dr. Fraser* gives the following, as the 
results of his post-mortem examinations in the Montreal General Hospital : — 

" The morbid appearances found on dissection are venous congestion, 
with effusion of serum on the surface, in the ventricles, and base of the 
brain, but no trace of active inflammation. When tlie case has been com- 
plicated with bronchitis, I have found the bronchial mucous membrane 
throughout tumid, swollen, highly vascular, and containing much mucus ; 
the vascularity extending to the submucous tissue, with congestion and par- 
tial hepatization of portions of the lungs. When diarrhoea has existed, 
the small intestines, especially the lower portion of the ileum, has presented 
the appearance of active congestion of its mucous coat, which was slightly 
thickened, without being softened ; some patches had the appearance of 
sanguineous extravasation, not unlike the maculae observed on the skin. 
When the patient had a jaundiced appearance, a common occurrence in this 
epidemic, I have found the liver enlarged from congestion, presenting a 
bloody and bilious appearance when cut into, and the gall-bladder distended 
with inspissated bile, thick enough to maintain its form when deprived of 
its covering. When there has been only a slight bilious tinge of the skin 

* Brit. Amer. Jour. vol. iii. p. 61. 



INTERIOR VALLEY OF NORTH AMERICA. 437 

and conjunctivae, the liver presented the same appearance in a less degree, 
the bile in the gall-bladder being about the consistence of treacle." 

A large proportion of the patients attended by Dr. Fraser had maculae, 
diarrhoea and bronchial congestion. Those which he examined after death, 
seem to have been citizens of Montreal. 

Dr. Badgley* made twelve post-mortem inspections in the same Hos- 
pital, but his patients, like those of Dr. Fraser, do not appear to have been 
immigrants. The following is an abridged statement of what he saw. 

" The dark purple petechial spots which existed on various portions of 
the body before death, remained distinct." 

" On dividing the integuments of the head, a large quantity of dark- 
colored blood always escaped ; there was invariably a strong attachment 
between the calvarium and dura mater, ecchymosed spots on various por- 
tions, and of different sizes. On removing the former, the sinuses, and 
especially the lateral and torcular Herophili, were full of, and prominent 
with, similar dark-colored blood. On removing the dura mater, effusions 
between the pia mater and arachnoid were visible, occupying spaces of from 
a quarter of an inch to an inch of surface, the arachnoid sensibly elevated 
by the collection ; on slitting open these sacs, a thin and clear watery fluid 
escaped ; there was no appearance of lymph, nor of pus. The brain proper 
possessed a good consistence ; the cerebellum was always rather softened ; 
the surface of the hemispheres presented a universal network of dark red 
vessels ; the pia mater was easily detached from the brain surface j bloody 
points were abundantly exposed to view with every section of the brain- 
substance ; the great commissures, and indeed the white or central medullary 
portions generally, were, if anything, slightly softened ; the lateral ventri- 
cles contained from one to three drachms of limpid fluid — sometimes this 
appeared to be a little discolored ; some of the same fluid was always found 
between the arachnoid surfaces, at the base of the brain; in two cases, 
there was upwards of ten drachms ; in all, the cineritious portions of the 
convolutions, thalami, corpora striata, and arbor vitae were palpably darker 
in color than usual, while the choroid plexuses in the lateral ventricles were 
flaccid, and resembled in color the gills of a fish many hours out of water. 
On raising the body, fluid, variable in quantity, always flowed out of the 
vertebral canal." 

" On opening the thorax, in the majority of the cases examined, no trace 
of recent pleural inflammation was detected in them ; there were old adhe- 
sions existing between the pleural surfaces on the right side ; in several there 
was oedema of the upper and the thin margin of the middle lobes ; fluid, 
variable in quantity, was found at the base of the thoracic cone, on both 
sides in all, but no flocculi of lymph ; extensive congestion presented itself 

* Brit. Amer. Jour. yol. iv. p. 88. 



438 THE PRINCIPAL DISEASES OF THE 

in the lungs of all, and to a striking degree, as was anticipated, in the in- 
ferior and posterior portions j the bronchi contained more or less frothy 
mucus, sometimes partially tinctured of a reddish color. The bronchial 
mucous membrane was iu these cases full and swollen; the sub-mucous 
cellular tissue also infiltrated, especially towards the back part of the lung; 
there was no abrasion nor softening of the former; nor was there false or 
adventitious membrane upon it. I never met with genuine hepatization of 
the lung, the solidifications appearing to be only the result of serous extra- 
vasation, consequent upon the congestion of the parenchyma; for on compress- 
ing these portions, a considerable quantity of the contained fluids could be 
forced out without breaking down their structure." 

" In all the cases, the heart was soft and flabby, resembling, in con- 
sistence, a mass of dough. Its size was natural, but wanting its nourish- 
ment, it impressed one with the idea of its volume being diminished. The 
pericardium contained in all a variable quantity of fluid, generally slightly 
reddish, without lymph or adhesions; the inner membrane was smooth, having 
a roseate color ; the same thing was observed as to the endocardium ; in 
all the cavities, auricles as well as ventricles, there were masses of blood, 
very soft, of a yellow color, caught sometimes between the musculi pectinati, 
or the chordas tendineae, and the loose edges of the valves/' 

" The lining membrane of the aorta and its branches, was infiltrated; the 
blood contained in them was invariably fluid, dark-colored, giving off a 
peculiar odor." 

" I hazard the idea that the ammoniacal odor emanating from the living 
body, so strong on opening the large cavities and so striking on receiving 
some of the blood out of the vessels, arteries as well as veins, into the hand, 
were all due to the same condition of this fluid ; the actual presence of 
ammoniacal salts, one of the surest proofs of the putrescent condition of the 
vital fluid; in fact, to speak paradoxically, of the existence of death during 
lifer 

"On turning over the abdominal flaps, no appearance of recent inflamma- 
tion or any of its results were visible as regarded the peritoneum, except in 
the case of the young woman already adverted to, and who aborted be- 
tween the fourth and fifth month." 

" There was more or less fluid found in the depending part of the peritoneal 
sac in every case, and the investing portion of this over the intestines and 
other abdominal organs communicated to the fingers an extraordinary sapo- 
naceous feel; the mesenteric glands were enlarged in several of the cases, 
presenting a darkish, yellow-colored matter, easily broken down ; there was 



INTERIOR VALLEY OF NORTH AMERICA. 439 

hypertrophy, with softening of the liver and spleen generally, the interior 
of the former presenting a more brown appearance than usual, while that of 
the latter was almost purple ; the consistence of both was diminished ; the 
outer surface of the spleen gave the appearance of its being puckered or 
wrinkled from absence of matter within, and consequent contraction of its 
proper investment ; the gall-bladder was usually fully distended with thick 
darkish bile, like thin treacle ; there did not appear to be a diminution in 
the calibre of the biliary ducts ; there was nothing abnormal in the pancreas ; 
the stomach and intestines all presented great congestion, both externally 
and internally j they all contained a large quantity of fluid and pultaceous 
matter of a yellowish color, acid and persistent odor. In only one case did 
I perceive a thickening of the coats of the former, and in this one only did 
I discover anything approaching to a softening or separability of the mucous 
coat, which, from its loosening in pretty large flakes, I attributed to soften- 
ing in the submucous cellular tissue. Ecchymoses of the depending intes- 
tines were generally noticed, and in most of the cases, isolated patches of 
discoloration, of sizes from a quarter of an inch, to three or four inches, and 
in one case, to the extent of upwards of eight inches, which were visible on 
the corresponding mucous surfaces, were seen. I did not find a single case 
of ulceration of the glands of this tube j all the glands, both solitary and 
aggregate, were enlarged, sometimes irregular in their form, with a dark 
purple or blackish point or nucleus in their centre ; sometimes merely ele- 
vated above the surface, thoroughly congested or hemorrhagic." 

When at Grosse Isle, I was told that the occupation of the physician was 
so great, as to leave no time for post-mortem inspections, a truth that was 
obvious at a single glance. In the immigrant hospital of Montreal, such 
examinations were prevented, according to Dr. Badgley, by popular pre- 
judice. 

VI. Treatment. — The conviction of all the medical gentlemen with 
whom I conversed was, that after the fever had become established, no 
method of treatment could shorten it. Yet cases terminated at every point 
of time, from two or three days up to as many or twice as many weeks. The 
early terminations were generally in death. The following outline, from 
the pen of Dr. Douglas, gives the method pursued at Grosse Isle, where, 
perhaps, as many were treated as at all other places on the St. Lawrence.* 

" The treatment was necessarily modified in different cases, according to 
the predominance of diseased action in the different organs, whether the 
brain, chest, or abdomen. 

" General bleeding was rarely employed ; as few cases were seen in the 
very outset, when this remedy, if used at all, is alone justifiable. Many of 
the medical gentlemen in charge of the hospital at Grosse Isle last season 
had great faith in emetics in arresting the disease ; but all, sooner or later, 

* Brit. Amer. Jour. vol. iii. p. 283. 



440 THE PRINCIPAL DISEASES OF THE 

gave up their use, from a conviction of their utter inemcacy. Cleanliness, 
quietness, cool drinks, gentle aperients of calomel and rhubarb, or senna 
and salts, so as to produce two or three stools in the twenty-four hours, with 
three half pints of gruel or arrowroot per diem for diet, were the chief 
means resorted to during the progress of the fever. If head symptoms showed 
themselves, the douche was used, and a single fold of linen cloth wet with 
cold water was kept applied to the shaved scalp. If there still existed great 
restlessness and insomnia notwithstanding these applications, recourse was 
had to hyoscyamus, as long experience has taught me that delirium, coma, 
and death often ensued, where attention to the important point of ob- 
taining sleep is neglected. Stimulants were rarely employed in the early 
stage of the disease j towards the close, and when the struggle came, brandy 
and wine were freely used, and when these failed to rouse the sinking 
powers, great benefit was often derived from the administration of large 
doses of gum-camphor ; doses of twenty to thirty grains three times in the 
twenty-four hours were given, in substance, reduced to a powder by means 
of a drop or two of spirits of wine. I have witnessed the most astonishing 
effects from the use of this drug in cases where there was almost total insen- 
sibility, a thread-like pulse, and complete loss of muscular power, as evinced 
by the sliding down in the bed. In such cases reaction has been brought 
on, and the flagging powers recalled by it, even when wine and brandy by 
the half pint had failed to stimulate. Tartar emetic was used with benefit 
where the disease showed itself in the chest. 

" In the abdominal affection, where there was much purging, starch ene- 
mata with laudanum were administered, and a rag wet with turpentine was 
applied externally. This form of the disease was always the most trouble- 
some and unmanageable, frequently baffling all the curative means employed. 
Alum, the mineral acids combined with opium, chalk with and without 
opium, and the whole catalogue of astringents, were tried by the young 
medical men, fresh from the schools, and having great faith in drugs. I 
did not find one who was not disgusted, sooner or later, with his pet 
remedy." 

The treatment at other places was substantially the same as this. How- 
ever, in Montreal, Professor Badgley* and some of his friends, under certain 
theoretical views (which, not making a part . of the natural history of the 
fever, I do not present), was led to place his chief reliance on the internal 
use of nitric, or nitro-hydrochloric (nitro-muriatic acid), with the early and 
liberal use of food. He sometimes gave a mustard emetic ) and very sel- 
dom cathartics. When constipation rendered the latter indispensable, he 
preferred the compound tincture of senna. " Diaphoretics and febrifuges 
were not even thought of." In conversation, Dr. Badgley gave me the 
following formula, as that which he had found most efficacious : — 

* Brit. Amer. Jour. vol. iv. p. 173. 



INTERIOR VALLEY OF NORTH AMERICA. 441 



R. — Nitric acid, gj. 

Alcohol, 
Water, 



l ' 1 each, ^iv.— Mix. 



An ounce to be given every hour, beginning early in the disease, and 
without much, so-called, preparation of the system. The effects of this 
administration, he assured me, was almost invariably a reduction of the 
frequency of the pulse, and an abatement of all the febrile symptoms. We 
bave in this mixture a kind of extemporaneous " sweet spirit of nitre," and 
when we recollect how long that familiar medicine has maintained its popu- 
larity in the treatment of fevers of various kinds, we may the more readily 
grant to Dr. Badgley what he claims for his prescription, when he states 
that he and two of his colleagues had, in private practice, treated more than 
fifty severe cases of the fever, without a single death. His patients, how- 
ever, were not immigrants. 



CHAPTER IX. 

ETIOLOGICAL GENERALIZATIONS. 



INTRODUCTION. 

In the preceding chapters, I have presented, with as much brevity as 
possible, a history of the principal visitations of continued fever which our 
Interior Valley has suffered. I propose now to generalize the facts which 
they embody, and incorporate with them such additional observations fur- 
nished by other countries, as may supply deficiencies, and assist in establish- 
ing correct general conclusions. The foreign will thus be engrafted on the 
native stock, not substituted for it ; the particular will become a part of the 
general, but still preserve so much of its individuality as to be distinguish- 
able. This continued recognition of our own facts is obviously an important 
duty ; for they are to be relied upon ; not because they have been more 
correctly observed and recorded, for such is not the case, but because they 
apply with absolute certainty to our own diseases, while those of distant 
countries may or may not have that applicability. In treating of our 
periodical and yellow fevers, this union of the exotic with the indigenous 
was not required; for those fevers prevail to such an extent as to supply 
equivalent facts for all that have been observed elsewhere. Should our 
continued fevers become more prevalent with the age of our settlements, the 
time will arrive when their etiological, pathological, and therapeutic history 
may be written in completeness without borrowing from other countries. 



442 



THE PRINCIPAL DISEASES OF THE 



SECTION I. 



CLIMATIC RELATIONS. 



I. Connection with Mean Annual Temperature. — Most of the 
epidemics and subepidemics of which notices have been given, have oc- 
curred in the middle latitudes of the settled portions of the Valley, that is, 
between the thirty-third and forty-third parallels. Are we to conclude, then, 
that these latitudes are most favorable to the production of typhous fevers ? 
Such would be the conclusion if we had no other data to reason from ; but 
there are such, and to these we must give attention. From the Army 
Returns of the United States and Great Britain, I have constructed the fol- 
lowing table, exhibiting, in connection with autumnal or periodical fever, 
the comparative prevalence of those typhous fevers which are recorded 
as " typhus" through twenty-three degrees of latitude, from Key West to 
Quebec. The table also gives the prevalence of a fever denominated 
" synochar' in the American Returns, and " synochus" in the British. This 
fever I regard as specifically the same with " typhus," the reasons for which 
opinion will be given in a subsequent chapter,; the two are therefore com- 
bined in a separate or third column. 



ZONES OF MILITARY POSTS. 



a 

a 






o a> 

a* 
a a 

o o 



I. Marine: Subtropical: six posts, from Key 
West to Fort Pike ; N. L. 24° 30' to 30° 30', 

II. Southern Inland: six posts,from Baton Rouge 
to Fort Gibson ; N. L. 30° 30', to 36° 30', . 

III. Northern Inland: six posts from Jefferson 
Barracks to Fort Snelling ; N. L. 36° 30' to 
45°,. 

IV. Lacustrine: seven posts, from Fort Dearborn 
to Fort Brady; N. L. 41° to 47°, . . . . 

V. Lacustrine : Canada West; fromN. L. 42° to 
45° ; period of ten years, 

VI. Northeastern Inland: Canada East; fromN. 
L. 45° to 48° ; period of ten years, . . . 

VII. The Canadas united: period of twenty years, 

VIII. Maximum station of each of the first four 
zones : synochus and typhus : — 

1. New Orleans, 

2. Fort Smith, 

3. Fort Armstrong, 

4. Fort Niagara, 



595 
700 

239 
237 

178 

26 
79 



151 
169 

59 
34 
12 

1 

5 



746 
869 

298 

271 

190 

27 
84 



29 
11 

8 

21 



96 
23 
18 
60 



30 
13 

9 

26 

5 

7 
6 



99 
23 
18 
63 



90 

131 
120 



By this table we see, that, with two exceptions, the amount of typhous 
fevers in the different zones is nearly the same throughout the whole. The 
exceptions do not arise from a greater general prevalence of the fever over 
the whole of the two zones, I. and IV. as exhibited in the table, but from 



INTERIOR VALLEY OF NORTH AMERICA. 443 

its greater prevalence in a single year at one post, the New Orleans bar- 
racks, in the first zone, and for a single year at another post, Niagara, in the 
fourth zone. These posts being thirteen degrees of latitude apart, neutra- 
lize each other, and leave the conclusion, that while the periodical fevers 
decrease as we pass through the zones from south to north, the typhous 
fevers remain substantially the same ; neither swell out in the middle 
region, nor become regularly more prevalent as we advance into the higher 
latitudes. Yet, this conclusion, although a legitimate deduction from the 
premises, cannot be correct ; and this brings us to study the bearing of the 
numbers in the seventh column of the table, which represents what are 
called " common continued fevers/' in the British reports. These numbers 
indicate a great prevalence in the Canadas, especially in Lower Canada, of 
that form of fever; while it is not even named in the American reports. 
Now what shall be said of this " common continued fever," standing side 
by side with "synochus" and u typhus V* I am disposed to believe it an 
assemblage of different febrile affections. 1. Cases of synochus not strongly 
marked; 2. Of disguised phlegmasias; 3. Of autumnal remittent fever, 
assuming a sub-continued type; 4. Of mere ephemeras. When, however, 
we conjecturally deduct the three latter classes, enough will no doubt still 
remain to justify the conclusion, that in Lower Canada continued fevers of 
the typhous type, are in reality more prevalent, sporadically if not epidemi- 
cally, than in the regions farther south. 

But these fevers do not continue to increase as we advance into colder 
climates, and I have little doubt that they diminish beyond Montreal, or 
the 45th parallel of latitude. Beyond that parallel, except on the banks of 
the St. Lawrence, the inhabitants are too few to justify a positive conclu- 
sion. Yet the southwestern coasts of Hudson's Bay, the shores of Lake 
Winnipeg, and the regions between them and the Kocky Mountains from 
the forty-eighth to the fifty-eighth degree of latitude, have many fur-trading 
establishments, in none of which do continued fevers appear to have prevailed. 
Other observations have been made in higher latitudes, with the same negative 
results. Thus Captain Parry spent two winters near the line which separates 
the temperate from the polar zone, and one far within the latter, and Captain 
Boss spent four successive winters in a harbor intermediate to the other two, 
and yet no typhous fevers occurred in their crews, although for a great part 
of their time they subsisted on a meagre diet, and inhabited close and 
crowded apartments, conditions supposed to favor the origination of such 
fevers in the temperate zone. Still farther, those naval officers saw many 
hordes of Esquimaux, who were crowded together in filthy and unventilated 
snow huts, and yet no mention is made of any form of continued fever as 
prevailing among them. 

In Europe and Asia these fevers cease long before we reach the northern 
limits of population. Thus in his travels through Southern Lapland, in 
1732, Linnaeus, who was a physician, and gave an account of many diseases 



444 THE PRINCIPAL DISEASES OP THE 

of that region, does not mention continued fever; and Wrangell and Errnan, 
in their journeys through Siberia nearly a century afterwards, are equally 
silent in reference to it. We are certain, then, that continued or typhous 
fever is limited by climate to the north as well as to the south. 

In our Interior Valley, continued fevers have their chief prevalence 
between the 32d and 48th parallels. In Western Europe between the 44th 
and 60th. Where the mean annual temperature rises above 62° or falls 
below 40° they prevail but little on either continent. The isothermal 
curves which best represent them in Western Europe are 48°-52°. In this 
country they have not prevailed sufficiently to justify a conclusion on this 
point. 

II. Relation to the Seasons. — For the study of our continued fevers 
in their relation to the seasons, the facts are not as full and precise as could 
be desired; yet some approximation to the truth may be made. If we bring 
together the chronological data afforded by the foregoing histories, and con- 
nect with them the prevalence of continued fever, we have twenty-six sub- 
epidemics, which bear the following relation to the seasons : Began to pre- 
vail, in winter, eight ; in spring, three ; in summer, three ; in autumn, 
seven ; not stated, five. Prevailing in winter, twenty-two ; in spring, 
twelve; in summer, eleven; in autumn, eighteen. Ceased in winter, but 
recurred the ensuing summer, three ; ceased in summer, but returned the 
following winter, two. We should be cautious in drawing conclusions from 
such limited and doubtful premises, yet the following seem warrantable. 
First, that our continued fevers make their appearance in every season, but 
begin more than twice as often in fall and winter, than in spring and 
summer. Second, that they prevail much oftener in autumn and winter, 
than in the other seasons, and most frequently of all in winter. Third, that 
they sometimes cease with the access of summer, reviving in winter, again 
to cease when summer returns ; and that the same remark is conversely 
true of winter. On the whole, they prevail more in cold than in warm 
weather, and this coincides with my own observations at Cincinnati, where 
the number of sporadic cases has generally been greater between the 
autumnal and vernal equinoxes, than in the other half of the year. The 
frequency of the commencement of these fevers late in autumn, compared 
with spring and summer, results, in all probability, from a union of their 
cause with that of autumnal fever in October and November. 

When we refer to the British and Irish histories of continued fevers, we 
find that on the point now under discussion, they obey the same law. At 
different times and places, they have commenced, reigned, and ceased, in 
every season of the year. Thus in relation to the seasons, they differ widely 
from periodical fevers. 

III. Influence op the Annual Range of Temperature. — We must 
now inquire into the influence of winter and summer extremes of tempera- 
ture on the prevalence of continued fever. For this purpose we may use 



INTERIOR VALLEY OF NORTH AMERICA. 



445 



the following data, drawn from places which have nearly the same annual 
mean heat. 



Places. 


Mean Temp, of Year. 


Of Winter. 


Of Summer. 


Range. 


Cincinnati, Steubenville, 
and Lewiston, . . . 

Paris, Vienna, and Ber- 
lin, ....... 

Dublin, London, and 
Edinburgh, .... 


50° 
50° 
49° 


31° 
34° 
39° 


70° 
65° 
60° 


39° 

31° 
21° 



From this table, it appears that the difference between the mean heat of 
winter and summer, in this valley, is equal to four-fifths of the mean tempe- 
rature of the year; on the continent of Europe, to three-fifths; on the 
islands of Great Britain and Ireland, to two-fifths ; or, to vary the expres- 
sion, the range from winter to summer is about twice as great in this valley 
as on those islands, while the continent of Europe holds a middle place be- 
tween the two. 

Now what is the comparative prevalence of the continued fevers in these 
different regions ? The answer is not difficult. It is inversely to the range 
of winter and summer heat, being least in the Interior Valley, greater on the 
islands, and intermediate on the continent of Europe. It is interesting to 
compare this climatic law of continued fever with those of yellow fever and 
autumnal fever. A mean summer temperature of 80° or above, with a 
yearly temperature of 65° or upwards, is necessary to the prevalence of 
yellow fever in our valley ; and an average summer heat of 60° or more, 
with a yearly heat of 40° or upwards, is necessary to the production of 
autumnal fever. Thus, as a general law, yellow and autumnal fever are in 
direct proportion to the heat of summer, while the continued fevers are in 
reverse proportion. Yet there is one point of view under which they con- 
form to the same law. They all prevail most where the range between 
winter and summer is least. Thus at St. Louis, the range is 42°, and yellow 
fever is unknown; at Natchez, it is 29°, and the fever prevails occasionally • 
at Havana, only 10°, and there the yellow fever is as constantly present as 
typhus fever in Dublin. In the latitude represented by Cincinnati, the 
range is 40°, and the prevalence of autumnal fever is moderate. In that 
represented by Baton Bouge, the range is 28°, and the fever prevails every 
year as certainly as continued fever prevails in Glasgow or Edinburgh. 

It appears, then, that while climates which present but a limited range be- 
tween their winter and summer temperatures, may, on that account, be exempt 
from some diseases, they are proportionably more subject to others; in the 
lower latitudes to yellow and periodical fevers; in the higher to typhous 
fevers. But, how is it that the warm winters and cool summers — the moderate 
annual range — of Great Britain and Ireland, favor the production of con- 
tinued fevers ? This question cannot be answered without the introduction 



446 THE PRINCIPAL DISEASES OF THE 

of another meteorological fact, viz., that where the range between winter and 
summer is small, the diurnal range is correspondingly small. Thus in those 
islands it is much less than in the zone of the Interior Valley with which 
we are comparing them. Now sudden and violent changes and extremes of 
atmospheric heat tend directly and powerfully to generate a phlogistic 
diathesis, which favors the production of phlegmasial diseases, but not of 
typhous fevers. Such a diathesis, may, indeed, be regarded as a preventive 
of those fevers. But the moderate cold and heat of the British Isles may 
act indirectly by favoring atmospheric humidity, and to that we must now 
give attention. 

IV. Relations with Humidity. — Our continued fevers have not yet 
been studied in connection with the dew-point; but if we assume that it is 
high, in proportion to the contiguity of water and the elevation of tempera- 
ture, we are compelled to say, that such a state of the atmosphere does not 
contribute, in the Interior Yalley, to their production ; for the shores of the 
northern lakes and the banks of our rivers have been least affected. On 
the contrary, the fevers have prevailed most where there was but little 
water to be evaporated. On the other hand, those European countries in 
which they prevail to the greatest extent, have a humid atmosphere ; as every 
wind, except those from east to south (not of frequent occurrence), neces- 
sarily brings moisture from the Atlantic Ocean, the German Sea, the Baltic 
Sea, and the chain of lakes to its northeast, Ireland, England, and Scotland, 
being most exposed to this influence; and from the great prevalence of 
westerly winds, Ireland especially. Some of the enlightened medical his- 
torians of those islands have sought for a connection between these fevers 
and the quantity of rain ; but the latter is not a measure of the humidity of 
the air, which can only be ascertained by experiments on the dew-point. 

That itjs at all times very great, is generally admitted. The absence of 
extreme cold in winter and of high heat in summer, recognized under the 
last head, contributes to the same result ; for intense cold precipitates the 
vapor of the air, and extreme heat raises it far above the point of saturation, 
and makes it to our sensations dry, when its absolute quantity of vapor may 
be great. Dr. Fergusson* has laid much stress on the " moist-cold " of 
those countries, as a cause of their fevers ; and, e conveiso, we may assume, 
that the dry-cold of our Valley is a cause of their comparative infrequency. 
In Great Britain and Ireland, the moist-cold is increased by deficiency of 
fuel ; a deficiency which is but little felt, even by the very poorest classes, 
in this country. The shortness of spring with us deserves also a notice in 
this connection. If the fuel of our poor be exhausted by the end of winter, 
they soon bask in a sun as hot as that of midsummer in Ireland or England; 
but the poor of those countries are exposed, without the benefit of culinary 
fire, to many weeks of cool and damp weather, which may be even worse 

* Edin.Med. and Surg. Journal. 



INTERIOR VALLEY OF NORTH AMERICA. 447 

than the atmosphere of their crowded huts in winter, notwithstanding they 
are then but imperfectly warmed. 

Of the immediate pathological effects of such exposure it is not possible 
to speak with certainty; but we may conjecture that the solids are thereby 
enfeebled, the functions of the skin and liver impaired, and a deteriorated 
condition of the blood generated ; but this inquiry must be reserved for a 
subsequent head. 



SECTION II. 

TOPOGRAPHICAL RELATIONS. 

Notwithstanding what was said in the preceding section of the influ- 
ence of a cold and humid atmosphere in the production of continued fevers 
in England and Ireland, it must be stated, that most of our subepidemics 
and sporadic cases of typhous fever, have occurred on rolling or mountainous 
surfaces, and not on the banks of the larger rivers or the coasts of the 
northern lakes. It may not be easy to explain this discrepancy; but in 
reference to the mountains I may remark, that the inhabitants generally 
occupy their valleys, and that the contiguous peaks and ranges, rising from 
one to two thousand feet above them, act as coolers, and condense the 
ascending vapor not less than that which arrives from a distance, thereby 
imparting to the air a considerable degree of humidity. These remarks, 
however, are not applicable to the zone of hilly or broken country, which, 
gradually sinking and becoming more level, stretches from the Apalachian 
mountains to the Mississippi ; the sub-alpine side of which is at least as 
obnoxious to continued fevers as the mountains themselves, and far more sub- 
ject than the portions which lie nearer that river. The mineral character of 
the subjacent rocks affords no explanation; for where it is the same, as for 
example, within the Pennsylvania and the Illinois coal basin, the preva- 
lence of typhous fevers is very different. We must, then, refer to the 
organic matters which rest upon or mingle with the soil. In the moun- 
tainous and hilly regions, these are washed away by the rains to be trans- 
ported and deposited in the lower valleys. Now, those portions of the . 
country from which this transportation is made are most infested with con- 
tinued fevers ; those to which it is made are least infested ; the reverse of 
which is true of the periodical fevers. Hence, to the east of a median line, 
drawn parallel to the mountains and the Mississippi, the people suffer but 
little from periodical fevers — to the west as little from those of a continued 
type. 

Here, then, is a species of antagonism, which suggests that the conditions 
favorable to the production of the former, tend to prevent the latter. And 
this brings me to say, that our Army statistics embodied in the table, p. 442, 
do not correctly represent the amount of continued fever in the latitudes of 



448 THE PRINCIPAL DISEASES OP THE 

the different posts, but only at the posts themselves, which are generally 
situated in alluvial, and, so called, malarial localities. 

All this is sustained by a reference to the British reports. Both con- 
tinued and periodical fevers prevail in Canada West. The flat, fertile and 
wet surface of that region generates the latter ; while the low temperature 
favors the production of the former. Thus the influences are combined, 
and Dr. Stratton, as we have already seen, has described a part of these 
cases under the designation of " continued malarial fever. " When we 
advance into Canada East, we reach a still colder climate, with a much more 
sterile soil, and a nearer proximity of mountains, and there periodical fevers, 
especially intermittents, nearly cease — are replaced by continued fevers. 
The difference between the two Canadas in reference to intermittent fever, is, 
according to the table, as 178 to 26; and yet these numbers do not show the 
whole, for it is well known that many cases of intermittent fever occurring 
in Canada East were contracted in Canada West. The allowance to be 
made for this is estimated by Major Tullock, the British editor, at 10 per 
cent. ; so that 180 to 24 would more nearly express the actual relation. On 
the other hand, the relation between the continued fevers of the two pro- 
vinces is expressed by 90 and 131 ; but as many cases were contracted in 
Lower, and began in Upper Canada, we should subtract 9 from the former 
number, and add it to the latter, when we obtain as a true expression 81 
and 140, or three times as many cases of continued fever in the colder or 
more barren province as in the other. Thus it seems to be true of the whole 
Interior Valley that the cause of periodical fevers is antagonistic to that of 
the continued. 

We may now turn to the effects of clearing and cultivation. Although 
sporadic cases of continued fever have occurred from the beginning of im- 
migration into those parts of the Interior Valley which are still infested 
by that disease, it is undeniable that cultivation has diminished the amount 
of periodical, and increased that of continued fever. 

When we look to the degree in which the forest has been replaced by the 
products of agriculture, and especially to the length of time the soil has 
been tilled, we find that where these labors have been longest performed the 
continued fevers are cseteris paribus most prevalent. This is the case in 
the western part of Pennsylvania, and adjacent parts of Ohio; in the 
neighborhood of Cincinnati, in the middle and northern parts of Kentucky, 
in Middle Tennessee, and above all in Lower Canada, the dates of the first 
settlements in which places (a necessary element of medical history), may 
be found under the appropriate heads in Book I. Part I. The comparatively 
very early settlement of the lands along the estuary of the St. Lawrence, 
is probably one of the greatest causes of the remarkable prevalence of con- 
tinued fever, and of that abatement or disappearance of periodical fevers, 
which has taken place more or less within the memory of the present gene- 



INTERIOR VALLEY OF NORTH AMERICA. 449 

ration, as I have been assured by Dr. Hall ; they being now unknown in 
places where they were formerly prevalent. 

Now this long-continued cultivation may operate to increase the amount 
of continued fever in two ways, a negative and a positive ; thus, it may de- 
stroy or prevent the agencies which produce the antagonistic periodical 
fevers, and so allow the continued to come forward, or it may generate new 
and undetected agencies j and in that manner give a positive impulse to the 
increase of the latter. Perhaps it operates in both modes. When we con- 
trast the age of European settlements with those of America, we doubtless 
see one cause of the greater prevalence of continued fever, in the former — 
of periodical, in the latter ; and may foresee that time will bring forth a 
change in the type of our fevers. 

But towns and cities are the offsprings of old settlements, and these have 
been regarded as especially favoring the production of continued fevers. It 
does not appear, however, that such is the case in our Valley. I could not 
learn that Quebec, the oldest city of the Valley, and in some of its parts 
most densely peopled, is more subject to continued fevers, than the open 
villages and country around ; and the same remark is applicable to Montreal. 
Pittsburg is less infested than the long-settled ridges south of the Monon- 
gahela River ; Wheeling less than the eastern end of Ohio, opposite to it, 
and Cincinnati has never experienced such an epidemic as occurred on the 
adjoining Walnut Hills. In fact most of the local epidemics and sub-epi- 
demics of which I have been able to collect any accounts, have prevailed in 
the country and the villages ; which is not the case in Europe, where on the 
whole the cities suffer most. 



SECTION III; 

PHYSIOLOGICAL AND DOMESTIC INFLUENCES. 

I. Physiological. — Continued fevers in this as in other countries, are 
apt to attack the young rather than the aged. In the absence of statistics, 
I may express the belief that a large majority of patients are under thirty 
years of age. Early life is then a predisposing cause. 

Of the difference of liability from temperament, I cannot speak. 

In regard to sex, males are more liable than females, and a greater pro- 
portional number of them die. The hospital returns of England, Ireland, 
and Scotland, accord with the latter, but reverse the former statements, for 
more females than males are admitted. 

On the liability of races, I cannot speak with confidence. Whites and 
blacks appear to be equally liable. The former may be divided into four 
classes : Anglo-American Hispano, Indian or Mexican, Franco-American or 
Canadian, and the emigrants from Great Britain and Ireland. Of the three 

vol. ii. 29 



450 THE PRINCIPAL DISEASES OF THE 

first, it cannot be affirmed that either class is more obnoxious to continued fever 
than another. But I am disposed to think that the fourth are more liable 
than the others. It is not uncommon to see Irish immigrants taken down with 
the disease many months after they have reached the interior of the Valley, 
and the reports of the British army in Canada, p. 442, give an account of 
cases so far beyond that of the United States army in the same latitudes, as 
to suggest a predisposition to continued fever in the royal troops. This 
may possibly consist in a national peculiarity of constitution, but more pro- 
bably depends on impressions made on the system before leaving their native 
country. In support of this opinion, I may mention that a physician, name 
forgotten, of Lower Canada, informed me that where he lives he had never 
seen but three cases of intermittent fever, two of which occurred in indi- 
viduals who had spent the preceding autumn further west, where it prevailed, 
but were not then attacked ; and the other, ten years before, bad resided 
in the western part of New York, where that fever was endemic. 

II. Domestic and Social. — We never ascribe either yellow fever or our 
periodical fevers to domestic conditions ; but in all the kingdoms of Europe, 
where continued fevers prevail, they are the fatal scourge of the poor, 
though extending more or less to those in comfortable circumstances. The 
evils of poverty in this country, not less than the proportion of poor, fall as 
far below what those kingdoms present, as the prevalence of typhous fevers 
here is below their prevalence in Europe. Thus corresponding observations 
in different regions which differ widely in their social and domestic condi- 
tion, contribute to establish truth or expose error. 

We have seen that our typhous fevers prevail rather more in the country 
than in the cities. The domestic condition under which the poor of the 
latter live, are much better than those to which they are subjected in Europe. 
Their dwellings are not in courts and closes, but generally stand full on the 
margin of the street, have uncovered yards in the rear, are often but one 
story high, and seldom more than two, not compactly jammed together, are 
better warmed in winter, are kept in a cleaner condition, and lodge fewer 
inmates, than the houses of the poor in Dublin, Glasgow, or Edinburgh. 
The rarity of the fever under these mitigated circumstances, harmonizes well 
with its greater prevalence where all of them are aggravated. 

Poverty, in the Interior Valley, seldom brings the despondency and 
mental wretchedness which are its offspring in Europe. There is no lack 
of diversified occupation ; large masses of those who depend on the labors of 
one day to furnish their families with food and fuel for the next, are never 
thrown out of employment, and if at any time, there is in the cities, a defi- 
cient demand, the open and thinly peopled country presents inexhaustible 
resources to the working man and his family. Our German, English, and 
Welsh immigrants are inclined to disperse themselves, and cultivate the soil; 
but the Irish are prone to congregate in the purlieus of the cities, where, at 
no distant time, under the rate of influx which has prevailed for several 



INTERIOR VALLEY OF NORTH AMERICA. 451 

years, unless there should be a reformation in their domestic habits, we may 
expect to encounter the epidemic fevers of their native land. 

In the Interior Valley, epidemic famine is unknown, and although poverty 
may sometimes reduce the variety of articles on which the poor subsist, it 
scarcely ever diminishes, for any considerable time, either the healthy cha- 
racter or the amount of food consumed. In nearly all the epidemics and 
subepidemics which have been described, there was no previous lack of 
nourishing diet. One exception deserves to be recalled. The students of 
Lane Theological Seminary, near Cincinnati, left to decide on their diet, 
had nearly abjured animal food, and many subsisted on bread and molasses, 
or other articles of a like kind, at the same time repudiating tea and coffee. 
Their habits were cleanly, and their lodgings not crowded. Now, the out- 
break of fever in this little community, independently of known contagion, 
sustains the conclusion that deficient nourishment is one of its causes. In 
two Southern epidemics, p. 415 and p. 375, the fever seemed to originate in 
negro cabins. These are often crowded at night, are seldom kept very clean, 
and still more seldom well ventilated. How those negroes might have been 
fed, cannot be known, as every master does not come up to the standard 
which public opinion has established, — a much higher dietetic standard than 
that of the poor in Europe. In the absence of a precise knowledge of the 
circumstances under which the fever arose in these cases, we may fairly 
assume that deficient diet was not of the number, and are thrown, therefore, 
upon crowded, filthy, and unventilated lodgings, if we do not admit the in- 
troduction of contagion, of which there was no suspicion. 

On the whole, it may be affirmed, that in the Interior Valley, continued 
or typhous fevers have repeatedly prevailed among those who were ade- 
quately nourished with healthy food; but this does not prove that an 
insufficient or insalubrious diet may not favor the production of these fevers. 
It would be more logical to say that the diet on which we live is one reason 
why they prevail so little ; and that when they do arise, it is from other 
causes which our full feeding cannot avert. One or more of the physicians 
of Ireland have expressed a doubt as to the influence of famine in the pro- 
duction of these fevers ; but the opposing testimony seems to be conclusive. 
This testimony will, to some extent, come before us in the next section ; 
and instead of introducing it here, I will finish with a general remark 
suggested by the etiological inquiries through which we have passed. 

In both Europe and America the geographical and climatic limits of the 
continued and typhous fevers are nearly the same with those of the glutinous 
cerealise and the potato. Some one or more of these plants enter largely 
into the diet of the whole people, and a single one frequently constitutes 
nearly the whole sustenance of the poor, who are everywhere the chief 
victims of these fevers. That the grains of some of the cerealia are liable to 
deterioration during their growth has long been known. Thus wheat varies 
greatly in its qualities in different seasons ; and sometimes affords a flour 



452 THE PRINCIPAL DISEASES OF THE 

which produces nausea and gastric distress; procuring for it the epithet 
sick-wheat. It is also liable to become ergotized; though in a far less 
degree than rye. The ergot of this grain is well known to possess active, 
and in large doses, poisonous properties. The deterioration of the potato 
during its growth, and even the development in it of a deleterious principle, 
are matters of history. I refer to these facts, as indicating that the nitro- 
genized amylaceous grains and tubers may perhaps undergo changes of 
which as yet we know nothing, rendering them injurious to health. 

The connection between famine and fever is generally received as a fact. 
But may not the causes which diminish the quantity of the articles just 
named, transform some of their normal and nutritive elements into hetero- 
logous compounds, and thus combine insalubrity with scarcity, in the pro- 
duction of the typhous fevers ? In times of famine the worst articles of 
diet inevitably fall to the poor - } and they are the greatest sufferers from 
the fevers which then arise. 



CHAPTER X. 

ETIOLOGICAL GENERALIZATIONS CONTINUED; SPORADIC AND 
EPIDEMIC PREVALENCE; CONTAGIOUS PROPAGATION. 



SECTION I. 

SPORADIC TYPHOUS, PRIMARY AND SECONDARY. 

I. Primary. — In common with my brethren of the Interior Valley, I 
have seen too much of primary and sporadic typhous fever to doubt for a 
moment that cases which by their symptoms, progress, and duration, could 
not be distinguished from epidemic typhous, may originate independently 
of contagion, and terminate without generating it. In one year, a single 
case only may occur in a neighborhood, in another there may be several ; 
in another the number may almost justify the epithet subepidemic. Such 
cases are strictly non-contagious. Some of them can be traced up to a 
residence in confined and filthy habitations ; but others appear under cir- 
cumstances of comfort and cleanliness, which involve their origin in 
mystery. 

II. Secondary. — Occasionally our autumnal remittent fever instead of 
terminating by a crisis in the second week, or assuming an intermittent 
form, takes on a continued type, and simulates an original typhous so closely 
that a diagnostic distinction between the two is impracticable. This ten- 
dency is greater in the higher than the lower latitudes, and much stronger 
in some autumns than others. It is common to ascribe it to improper treat- 



INTERIOR VALLEY OF NORTH AMERICA. 453 

ment; but those who concur in this opinion, differ widely as to what that 
treatment is. One physician attributes it to excess of venesection and other 
enfeebling measures; another, to the neglect of those measures, and the 
premature exhibition of tonics and stimulants. I have seen it repeatedly 
occur under these opposite modes of treatment, when carried to excess; and 
cannot but regard it as indicating that all idiopathic fevers have many 
pathological traits in common. Had not observation taught us otherwise, 
we should no more expect to see a case of synochus put on the aspect of 
typhus mitior, than a case of remittent autumnal fever. The eruptive fevers 
often, and the phlegmasia now and then, display a typhous proclivity. It 
would seem that the word typhous, in a pathological sense, expresses a 
certain condition of the system, which may be preceded by different febrile 
states, induced by a great variety of remote causes ; but this subject will 
fall under a future head. I have never seen this secondary typhous propa- 
gated by contagion. Many cases may occur in a single autumn, but they 
appear as independently of each other as the remittent fever, which may be 
said to be their pathological cause. We must not confound this state of 
autumnal fever with that which is denominated malignant or congestive ; for 
their symptoms, although in many cases equally portentous, are different, and 
while the former appear oftenest in dry and elevated places, the latter are 
generated in hot, depressed, and paludal localities. There are, however, 
many exceptions to this remark. 



SECTION" II. * 

CONTAGIOUS PROPAGATION. 

I. Of our Endemic Typhus. — It has just been stated, that in various 
parts of the Interior Valley, sporadic cases of typhous fever occur, which 
cannot be referred to contagion, and do not propagate themselves by it ; 
yet the local subepidemics which have been described, furnish strong evi- 
dence that we have also typhous fevers which do propagate themselves in 
that mode. Without repeating the narratives, I may refer to the fevers 
which prevailed at the Sault St. Marie, near Lake Superior, p. 422 ; at 
Taylorsville, Pa., p. 381; at Parisburg, Va., p. 370; at Lane Theological 
Seminary, Ohio, p. 392 ; in Maury County, Tenn., p. 413 ; and in Benton 
County, Ala., p. 415. Other subepidemics have evinced the same pro- 
perty, but in a less decided manner. While, however, I cite these observa- 
tions, it is proper for me to say, that I have not met with contagious pro- 
pagation in my own practice ; and have therefore been led to look to Europe 
for additional proof. This as we have already seen she has to a certain ex- 
tent sent to us, by her emigrants to Quebec, but as the subject is of deep 
interest, I propose to continue and extend the inquiry. 

II. Contagion in Europe. — While the continental historians of con- 



454 THE PRINCIPAL DISEASES OF THE 

tinued fever barely admit the contagiousness of some of its forms, the physi- 
cians of Great Britain and Ireland, with almost perfect unanimity, speak of 
contagious propagation as a familiar and perfectly established fact. Many of 
them, indeed, prefer the word " contagious," when " typhus " alone would 
be more appropriate. The habitual and often indiscriminating use of that 
term, seems indeed to suggest that there is no typhous fever, which is not 
contagious — none which has not arisen from contagion. Various conditions 
are admitted as favoring the spread of typhous, but their influence it is said 
is limited to two effects : first, the retention and accumulation of conta- 
gion around the patient, whereby it acts upon the systems of those who 
approach him with greater energy ; and, secondly, changes in the condition 
of their systems, which render them more vulnerable to the action of the 
specific and only cause. Those who hold to this exclusive origin, believe 
that the fever always exists, at least sporadically, in some part of the 
United Kingdom, but cannot generate an epidemic except when the condi- 
tions to which I have referred are present. According to these views, if 
those conditions could be permanently destroyed, epidemic typhous would 
cease ; and, on the other hand, if the islands were once rid of every case of 
that fever, and of every substance which might have imbibed the contagion 
it is said to generate, and neither should afterwards be imported, the fever 
would not reappear — the conditions which favor an epidemic prevalence 
might remain, or even be multiplied or augmented indefinitely, but the 
fever would not reappear for want of a specific virus. I cannot adopt this 
opinion, nor is it held by a majority of the distinguished men who have 
observed r nnd written on the subject. 

In seeking for the proofs of an exclusive or even general spread of typhous 
by contagion, I have not found them either numerous or conclusive. One 
which seems to satisfy the minds of many of the historians of the United 
Kingdom, is the sometimes rapid extension of the fever when it appears in 
a city or other locality ; but the opposite conclusion should be drawn from 
such a premise. Influenza, epidemic cholera, and yellow fever, non-conta- 
gious epidemics — often spread rapidly ; but measles and small-pox, known to 
be contagious, spread more slowly. Another and (to those who admit it) more 
satisfactory evidence is the successive occurrence of single cases in the same 
family. So much stress has been laid on this, that very learned and emi- 
nent men have proposed to arrest the rise of an epidemic, by a timely re- 
moval of every patient from the house in which he was attacked to a fever 
hospital. Now who does not see, that this successive, and often slow, inva- 
sion of the different members of a family, is at variance with a rapid diffu- 
sion of the disease through a community ; and thus the two arguments for 
exclusive contagion, invalidate if they do not nullify each other. But, is 
the succession of attacks, continued till the disease has run through a family, 
a conclusive argument in favor of contagion ? It certainly is not. A con- 
tagious fever might so extend itself, but such extension does not prove it 



INTERIOR VALLEY OF NORTH AMERICA. 455 

contagious. For, first, when a case of small-pox or measles appears in a 
family, all its susceptible members are apt to contract the disease, not from 
each other successively but from the first patient. Second, in numerous 
instances it has been impossible to trace up the fever of the first patient to 
contagion; jet, that which was to be proved was assumed, and all the subse- 
quent cases in the family were said to be derived from his. Third, if 
typhous could only arise from contagion, the inference would be correct ; but 
the question on which the case is brought to bear is, whether it may not 
arise from oilier causes ; and therefore, unless it were shown (by exclusion) 
that no other cause could exist, which cannot be done, those who believe in 
other causes, are at liberty to refer to them, as producing both the first and 
all the subsequent cases. Should it be objected, that if such (local or 
domestic) agencies originated the fever, it ought to have attacked all the 
members of the family at the same time, the obvious rejoinder is, that as they 
were all equally exposed to the atmosphere of the same patient, they should 
all have been seized at once, if he exhaled contagion. Under both hypo- 
theses we must call to our aid the differences of susceptibility which result 
from age, sex, temperament, idiosyncrasy and exciting causes, without which 
we cannot even explain the successive attacks in the same family, of our 
endemio-epidemic dysentery or autumnal fever. 

An evidence of contagion has been found in the continued prevalence of 
the fever in the neighborhood of the first case ; but this only takes place, 
when the topographical, domestic, and social conditions are the same ; and, 
consequently, if they could generate the first, they might produce the sub- 
sequent cases. Nearly connected with this, is the prevalence of the disease 
in one part of Dublin or Edinburgh, while other parts apparently in the 
same condition remain exempt ; and its prevalence in one town, while another 
hard by continues healthy, as in the instance of Galway, where, in 1822, ac- 
cording to Dr. Graves, it prevailed for three months before it attacked the 
village of Claddagh on the opposite side of the river, although the inter- 
course between the two places was not interdicted.* Now all this is equally 
true and equally inexplicable, of epidemic cholera and yellow fever, which 
do not depend on contagion. 

Another evidence of contagion has been found in the occasional occurrence 
of the fever in persons who lived under topographical and domestic circum- 
stances the opposite of those in which the fever was epidemic. The cause, 
it has been said, could not have been generated there. But might it not 
have been carried or have diffused itself there, and excited the disease in 
some of the most susceptible ? The advocates of a local epidemic origin 
can without difficulty reconcile such cases with their views ; and being ex- 
plicable on both hypotheses, they give no decided support to either. In 
our autumnal fever we often see the same phenomenon : many cases near 
the focus of (so called) malaria, and a few on the neighboring heights, 

* Dublin Trans., vol. iv. p. 408. 



456 THE PRINCIPAL DISEASES OF THE 

which are free from the topographical conditions of the plain below. Nay, 
we sometimes see those heights the chief seats of the fever, although the 
cause is assumed to be developed in some foul and humid adjacent valley. 

But the doctrine of contagious propagation has been maintained by a 
class of facts, differing somewhat from those which have been considered. 
Histories of local and insulated subepidemics, both on land and water, have 
been published to substantiate it, and from their number and the high respec- 
tability of their authors, the question might be supposed to have received a 
final answer. My limits do not permit an analysis of these histories, but 
nearly all that I have seen are obnoxious to the objection, that when the 
fever seemed to depend on contagion, there were present several of those 
local causes, which in the opinion of a large and respectable portion of the 
profession, may originate it, independently of contagion. A sound philo- 
sophical logic must reject such observations, or hold them in reserve until 
the question is settled by other proofs, when they will be found valuable 
for a different purpose. Of this kind are nearly all the naval histories of 
Dr. Thomas Trotter,* and Sir William Burnett ;f that by Sir James 
M'Gregor, of an epidemic on the Island of Jersey ;J that of the Galway 
fever by Dr. Graves, already quoted; and that by MM. Hufeland and Rich- 
ter, of the fever at Tornau in Prussia ;§ for in all conditions extremely un- 
favorable to health existed, and it might be rationally held that they were 
the real and exclusive causes of the fever. 

The contagionist, however, can afford to give up these, and all other 
equivocal or ambiguous facts and observations; for there are some which 
seem to be altogether unexceptionable. For example, what could be more 
to the point than the introduction of the Irish immigrant typhous into a dis- 
tant and healthy rural district of Lower Canada by two men from Montreal, 
as narrated on p. 432, and the spread of several of our own subepidemics, as 
already narrated, can only be explained on the same theory. Such facts 
can be far more definitely observed in a sparsely settled country, than in 
one thickly peopled, or in large cities. Yet in these there is an important 
observation which has been repeatedly made, viz., the spread of typhous 
among the people through whose country discomfited and sickly armies 
sometimes march, and in the cities which they enter ; as, for example, on 
the return of the French army from Moscow to Paris. 

In large cities it is obvious that but little reliance can be placed on par- 
ticular cases as evincing contagion, and of all I have seen cited, there is but 
one that seems worthy of introduction here. It fell under the observation 
of Dr. Alison. || In Edinburgh, Oct., 1827, the son of a shoemaker expe- 
rienced an attack of the typhous fever which was then prevailing. He had 
two apprentices, who worked in the house in which he lived, both of whom 

* Med. Naut. Lond.1797. t An Account of a Contagious Fever, &c, London, 1831. 

t Duncan's Med. Annals, vol. iii. p. 340. § Edin. Med. and Surg. Jour. 
II Edin. Med. and Surg. Jour. vol. xxxviii. p. 233. 



INTERIOR VALLEY OF NORTH AMERICA. 457 

were soon afterwards seized with the same fever, and returned to the 
families to which they belonged, one at the distance of an eighth and the 
other of half a mile. In one of these families, seven cases of the fever 
followed — in the other twelve; though both were previously in perfect 
health, and the fever did not then, before or afterwards, prevail in that 
neighborhood. 

But, although cities cannot often furnish facts of this kind, they afford 
abundant evidence of contagious propagation in their hospitals. 

These edifices are generally built in healthy locations ; external nuisances 
are not permitted to accumulate near them ; internal cleanliness is pre- 
served; the patients, as brought in, are washed, and their foul clothing kept 
out of the wards ; yet whenever and wherever typhous fever has been epi- 
demic, the proportion of physicians, students, apothecaries, superintendents, 
nurses, and servants, which have sickened with the fever, has been so great 
as to demonstrate that it was communicated by the patients. Quebec, 
Philadelphia, Dublin, London, Edinburgh, Glasgow, and many other cities, 
have contributed to this species of proof. If in a few fever establishments 
no such propagation has taken place, in a far greater number it has ; and 
the evidence afforded by the former is negative, while that afforded by the 
latter is positive. We should not, indeed, expect to witness contagious 
propagation in every fever hospital, for we have already seen that some 
forms, or at least some cases of that fever, are not contagious. And this 
remark suggests two questions : first, is there a contagious and also a non- 
contagious typhous, two specifically distinct diseases, often prevailing at the 
same time, in the same place, and so similar in their symptoms as to be 
confounded ? or is the secretion of contagious effluvia an accidental or con- 
tingent pathological event, which is sometimes absent and sometimes pre- 
sent in the same fever ? I state these questions without attempting in this 
stage of our inquiry to answer them. 



SECTION III. 

LOCAL OR SPONTANEOUS ORIGIN OF EPIDEMIC TYPHOUS. 

I. Having shown that in both America and Europe eases of epidemic 
continued fever are produced by contagion, we come now to inquire whether 
that fever, in an epidemic form, ever arises independently of contagion. 
The fact of the appearance and prevalence of the fever, in connection with 
poverty and its concomitants, unhealthy or deficient diet, cold, moisture, 
filth, crowded and unventilated apartments, idleness, despondency, and 
gloom, is admitted by every historian. But very different views are held as 
to the nature of the connection between these conditions and the typhous 
fevers. The contagionist says the effluvia from the body of the patient are 
confined, condensed, and rendered more virulent by these conditions ; he 



458 THE PRINCIPAL DISEASES OF THE 

asserts also that by their enervating influence on the system, they predis- 
pose it to be acted on by contagion ; thus he makes this combination a 
conditio sine qua non for every epidemic prevalence of the fever ; while con- 
tagion is held to be a causa sine qua non of the actual existence of the 
fever. When the conditions are present without the fever, he explains the 
anomaly by saying, contagion is absent ; when cases of the fever do not pro- 
pagate themselves, he ascribes it to the absence of the conditions. This 
hypothesis, which assuredly has in it great probability, may be illustrated 
by a fact drawn from the science of botany. Some parts of the earth's 
surface are so dry and sterile that they do not bear mushrooms, yet if a spot 
should be covered with the remains of plants and animals in decay, those 
plants immediately appear upon it. Formerly, they were said to be gene- 
rated by the decaying organic elements, without the previous deposition of 
seed, as certain etiologists say that fever is generated in particular localities 
without the aid of contagion. But the botanists have shown that the mush- 
rooms bear seed, which is so light as to float in the air. They have sown 
it, and cultivated these humble plants ; and now they infer that all mush- 
rooms grow from seed, a generalization which seems to be irresistible. 

The capacity of such a manured spot for quickening into life the seeds 
which chance to fall upon it, is not enjoyed by the unmanured, barren soil, 
on which they may likewise fall, and represents to us the predisposition to 
fever generated in the systems of those who reside in certain localities, 
which predisposition will not be present in those who live in a better way 
in localities of a different kind. Now, if any one should aflirm of a parti- 
cular spot where mushrooms might appear, that it was so distant from any 
other where they were known to grow, and so protected, that although those 
plants might generally spring from seed, they could not have had such 
an origin in that particular instance, how would his argument be met ? 
Undoubtedly by a reference to the simplicity, uniformity, and constancy of 
the laws of nature. If so, why may not the exclusive contagionist take the 
same ground, and, to borrow the language of another profession, " rule out 
of court" all the histories of epidemic typhous, where contagion could not 
hy possibility have been brought to bear on the system of any one affected? 
Most assuredly he is entitled to this advantage. He was required to prove 
contagion ; he did so, and then extended it by generalization to all cases of 
the fever. This was not unphilosophical, nor should he be called upon to 
prove its truth. The onus probandi is thrown on the other side. It is for 
that to show that his generalization is too extensive, and that there are 
continued fevers which do not spring from contagion. But how are they 
to do this, if deprived of so many observations as are excluded by the force 
of a severe logic ? If not allowed to refer to the multitudes in every great 
epidemic, who suffer attacks, without having been, as far as they or others 
know, exposed to contagion, and yet might have been ? The task, it must 



INTERIOR VALLEY OF NORTH AMERICA. 459 

be confessed, is difficult j but the believers in local origin are not at liberty 
to evade it, and to this duty we must now apply ourselves. 

1. We may be allowed to give some weight to the almost universal 
opinion of the medical world, that there are typhous fevers, of an epidemic 
character, which originate from local causes. 

2. It is not uncommon to see an epidemic arise in the different and distant 
parts of a city or district of country at the same time; in which instances, 
we generally find that the inhabitants are living under the same or similar 
conditions. Now, in these instances, the alternative is presented to us of 
believing that the fever arose from those conditions only, or that contagion 
was introduced simultaneously into the different localities, and every one 
must decide for himself which is the more probable. 

3. Every contagionist admits, as the result of observation, that the ema- 
nations from the body of the typhous patient are made and spread so slowly, 
that the deleterious atmosphere is of most limited extent ; and that a mode- 
rate ventilation so dilutes the contagion that it can no longer produce the 
fever in others. Now all this is at variance with the rapid spread through 
a city, which the fever sometimes exhibits to us. If we know the quantity 
and rate of action of an agent, and are shown certain phenomena, which 
from their nature might be ascribed to it, and their magnitude, and the time 
in which they were produced, are also made known to us, we can in 
general decide with great certainty, whether the assigned cause did or did 
not produce them. Thus if we found a man in deep narcotism, and were 
told that he had swallowed an ounce of laudanum, we should not hesitate 
to assign that as the cause ; but if he had only swallowed a drop, we should 
assign some other, on the ground that the malady was disproportionate to 
such a minute dose. 

4. In our thinly peopled country we now and then meet with a case of 
typhous, under circumstances of social insulation, so perfect and protracted 
that, in balancing probabilities, we are compelled to think it more likely to 
have arisen from local causes, than from contagion. 

5. Epidemic febrile constitutions have been generally admitted since the 
days of Sydenham. Almost every physician has observed them ; and modi- 
fied his practice to meet the requirements which they imposed. But how 
can such contaminations or meteorations of the atmosphere result from a 
personal contagion, so feeble in its properties, that ordinary ventilation and 
cleanliness will render it harmless to attendants on the sick. It may I 
think be safely asserted, that such atmospheric constitutions are not generated 
by morbid animal secretion. 

6. Although by the rule of evidence which has been recognized, I am 
precluded from referring to a great number of epidemics, which appeared 
to originate from local causes, but which mighth&ve sprung from contagion, 
there have been some in which the improbability of contagion is almost 



460 THE PRINCIPAL DISEASES OF THE 

transformed into impossibility, and they may therefore be eited as auxiliary 
evidence. 

a. Of this kind was the subepidemic at the Theological Seminary near Cin- 
cinnati; that of Maury County, Tenn., and that of Benton County, Ala., 
to which I might, perhaps, add the epidemic of Tazewell and Giles Coun- 
ties, in the most remote, sequestered, thinly peopled and mountainous por- 
tion of Virginia.* In each of these cases there was the highest probability 
that the fever had a local origin. But let us look to the Atlantic States 
and to Europe, b. The often quoted and authentic accounts of certain events 
in the Criminal Courts of England are directly in point. The prisoners, 
brought in a foul condition from filthy and unventilated cells, ivhere typhous 
fevers were not prevailing, empoisoned the court and bystanders, generating 
fevers which have ever since been regarded as of a typhous character. 

c. The British seventy-four gun ship Invincible, Mr. Kenning, Surgeon, 
sailed from Portsmouth, in the month of June, 1795, on a cruise off the 
coast of France.f On the first of July, some gentlemen in the cockpit 
were attacked with a mild remittent fever, which confined them but a few 
days. On the 9th day of that month, one of the sailors was seized with 
what proved to be continued fever, and by the 6th of August more than 
50 cases of the same kind had occurred. Among the characteristic symp- 
toms were delirium, coma, subsultus tendinum, petechia?, hemorrhages, and 
swelling of the parotid glands. After the first week of August there were 
other attacks of a slight and transient character. From the beginning of 
the subepidemic, " every precaution was taken to separate those that were 
ill from the rest of the ship's company." Mr. Kenning believed that this 
fever spread by contagion, and his superior medical officer, Dr. Trotter, 
adopted the same opinion; but I cannot concur in it, for there are no facts 
which go to show that typhus is contagious in the beginning, and the 
patients were removed to the sick berth as soon as they were attacked j 
where it does not appear they occasioned the disease in any of the attend- 
ants. New cases indeed contined to occur daily among the sailors where 
none of the sick were allowed to remain ; but no cases were generated where 
ihe exhalations from the bodies of the sick took place. It must be admitted, 
however, that under another aspect this history is not absolutely conclusive, 
for all the men that were taken might have been exposed to contagion before 
the vessel sailed, on which point the report is silent. If that were not 
the case, this is an example of the rise of a subepidemic from local causes. 

d. Doctor, now Sir James M'Gregor, of the British Army, has given the 
history of a fever, which bears upon the question before us. J " The 88th 
regiment landed on the 6th of June, 1797, in (the island of) Jersey, with 
400 men, all very healthy, and for nine months preceding their arrival in 
the island, the regiment ha'd been in the most healthy condition ." The 

* See p. 370. f Medicina Nautica, by Thomas Trotter, M.D. Lond. 1797. 

% Duncan's Annals of Med. for 1798, vol. iii. p. 340. 



INTERIOR VALLEY OF NORTH AMERICA. 461 

first case of fever happened on the 17th of July, between which and the 
18th of August, 54 cases occurred. According to Sir James, " the fever 
in every instance was the typhus, or that usually denominated low nervous 
fever." Now it cannot be affirmed that this fever was not introduced into 
the barracks from the people of the island, yet all the circumstances are 
opposed to a contagious origin. The author (a firm contagionist) says 
nothing of the existence of fever among the islanders, and assigns a variety 
of very obvious local causes for its origin ; while, moreover, the first case 
occurred in a lieutenant, who might have been among the people, the second, 
happening only two days afterwards, was a patient confined in the venereal 
hospital. Finally, although in consequence of their previous belief, the 
medical officers separated the sick from the well, and did all they could to 
prevent contagious propagation, twenty of the men were attacked within 
the first ten days. On the whole, it seems to me that the evidences of local 
origin are in this case almost conclusive. 

e. In the summer and autumn of 1798, a company of United States troops, 
lately recruited, were quartered in airy and comfortable barracks in the 
western precincts of Baltimore, where they enjoyed good health. On the 1st 
day of November, they were brought into the city, and crowded into a house 
not large enough to accommodate half their number. It was close, damp, 
and dirty. On the 19th of that month, three of them were taken down 
with typhous fever, and by the 18th of December, 120 out of 166 were on 
the sick list. The floors and walls were then scoured with hot lye, and all 
the articles of clothirjg subjected to the same process. The purification was 
completed on the 22d, after which, although the troops continued in the 
same place till after the expiration of the month, not a single new case oc- 
curred. Now it may be said that this fever was introduced from the city, 
and it is to be regretted that Professor Potter did not inform us whether it 
was then prevailing in Baltimore. His silence may perhaps be taken as 
evidence that it was not; and the sudden arrest of the epidemic by purifi- 
cation of the quarters seems to show that the origin of the fever was in 
local causes.* 

What additional facts might be found by a more extended bibliothecal 
research than I have the opportunity of making, I cannot of course know. 
The conclusion from those which have been presented must be, I think, that 
epidemic, continued, or typhous fevers have arisen from local causes, inde- 
pendently of contagion. And here the question put at the close of the last 
section returns upon us — can such fevers, which have this origin, be distin- 
guished by their symptoms from those which depend on contagion ? Do 
they constitute a distinct species ? These questions cannot be answered in 
the present stage of our inquiry. 

* Memoir on Contagion, by Nath. Potter, M.D., Baltimore, 1818. 



462 THE PRINCIPAL DISEASES OF THE 

SECTION IV. 

CONNECTION BETWEEN CONTAGION AND LOCAL ORIGIN. 

I. In the preceding sections, two facts were established : first, that in 
some epidemic typhous fevers there is contagious propagation; second, that 
others originate from local or strictly domestic conditions independently of 
contagion. It is the duty of the etiologist to reconcile or explain away the 
apparent conflict of these facts. This may be done, or at least attempted, 
in two modes : first, by showing that there are in the general group of con- 
tinued or typhous fevers two species, one always contagious, the other, 
always non-contagious; second, by showing that a fever which originates in 
local causes may become contagious. The first of these theories will be 
examined when we reaeh the nosological classification of these maladies ; 
and, therefore, I will only remark here, that all attempts to prove the 
existence of two species, distinguishable by the presence or absence of 
contagion, have hitherto failed. Let us, then, turn our attention to the 
second hypothesis. 

In proceeding to this inquiry, we must bear in mind that the question is 
not whether the exhalations from the body of a patient, in continued fever, 
are sufficiently copious to render the air of his room offensive, and, in a 
general hygienic sense, to contribute to its unhealthiness ; but whether he 
exhales a peculiar poison, capable of exciting in the healthy system, a fever 
of the same kind with that which had been produced in him by a cause or 
causes of a different sort. The question, in fact, is not one of quantity but 
quality; and may be illustrated in this wise. A person affected with 
autumnal fever may, by his fluid and gaseous excretions, render the atmo- 
sphere of his room impure and unpleasant, without producing in the systems 
of those around him the kind of disease under which he labors : another 
patient affected with a different malady, as, for example, measles, may add 
nothing to the sensible impurities of the air, and yet exhale into it a gaseous 
contagion that will generate the same specific form of disease in those who 
breathe it. The inquiry before us is, whether a case of typhus, not pro- 
duced by contagion, can thus propagate itself? When a number of persons, 
either sick or well, are crowded into a close, confined, and dirty room, it is 
often said, they generate contagion. No language could be more inaccurate. 
They exhale precisely what they would throw off elsewhere, and simply con- 
tribute to the foulness of the air. What deleterious compounds, if any, 
may be formed by chemical action in such an atmosphere, we do not know; 
but the term contagion has no applicability to them. It is quite as common, 
and quite as incorrect, to say, that a foul atmosphere around a typhous 
patient will cause him to generate contagion. This loose and vague phraseo- 
logy should be discarded. Contagion is not elaborated around, but within 
the body of the patient; and there is not the slightest evidence that the 



INTERIOR VALLEY OF NORTH AMERICA. 463 

common impurities of the atmosphere of the room in which he lies can so 
act or react on his system as to cause the secretion of contagion, if it would 
not otherwise have occurred. Much confusion has been created in this 
inquiry by the use of the term infection. Some have employed it to express 
the insalubrious condition of the room from accumulated impurities ; while 
others have used it to designate the gaseous contagion. Being thus made 
synonymous with both idio-miasma and contagion, it has so blended our 
ideas of them that all just conception of their distinctive properties and dif- 
ferent modes of origination, have in many minds been lost. 

But, let us return to the true question, which is, whether a fever, origi- 
nating from a miasm or malaria, elaborated in the atmosphere, can cause 
the secretion of contagion, and thus extend and perpetuate itself? 

'Observation only can decide this question; but we may, analogically, use 
the observations which have been made on diseases universally admitted to 
be contagious, as, for example, small-pox. This fever has been so long and 
extensively observed to arise from contagion only, that we speak of that as 
the universal cause, yet in doing so, in urging the generalization to the 
conditio ad absurdum, we find a logical necessity for admitting that the 
first case had a different origin j and hence the proposition is so restricted 
as to affirm that every case, except the first, had another case as its antece- 
dent or cause. When thus modified, the way is laid open for the admission 
that a typhous fever may originate independently of contagion, and yet 
perpetuate itself by contagion. Should this happen every year in every 
country of the world, and should there, on the other hand, never have been 
but a single originary case of small-pox, syphilis, or mumps, the difference 
would not be one of principle or kind, but of degree only j for it is easy to 
conceive of the repeated production of original cases as of a single one ; of 
an epidemic as of a sporadic generation. We cannot, however, declare that 
because a typhous fever, originating independently of contagion, may 
become contagious, it therefore does. Observation only can establish this 
as a fact ; and when established, continued observation, and nothing else, 
can inform us whether it is true of all typhous fevers, or of a part only ; 
for it must be admitted, that it might be true of some and not of others. 

III. In searching for facts to establish the generation of contagion in 
fevers which originate from different causes, great circumspection is de- 
manded. We must even exclude many- epidemics, subepidemics, and 
sporadic cases, which may, for aught we know, have arisen from other 
causes than contagion, and yet spread themselves by it ; inasmuch as we 
may not be able to prove that they did arise independently of contagion. 
When that cannot be shown, at least with high probability, the history is 
obviously inadmissible. Our books abound in examples of neglect of this 
rule ; not a few of which have been set by men of high and well-merited 
fame — even by those who have seen more than others of the fevers we are 
now studying ) and the reason is quite obvious. In a country like Ireland, 



464 THE PRINCIPAL DISEASES OF THE 

for instance, typhous fevers are always lurking somewhere, and, therefore, 
contagion (if they originate it) is never extinct. When, from local con- 
ditions, an epidemic arises, characterized by contagious propagation, how is 
it possible to tell whether that propagation is from pre-existing sporadic 
cases of contagious typhous, or a contingent morbid secretion of the patient? 



CHAPTER XL 

CLASSIFICATION OF CONTINUED FEVEKS. 



SECTION I. 

I. The classification of continued fevers has long been one of the 
opprobria medicorum. 

By some writers they have been distinguished by their origin or place of 
prevalence, as jail, ship, hospital, and camp fevers; but although some 
diversities of character may result from this diversity of origin, it cannot 
be doubted that they are essentially the same fever. The sources of 
diversity are obviously twofold. 

1. In such localities the insalubrious conditions will seldom be exactly 
the same, and consequently there must be some variety in their morbid im- 
pressions, which may run through the whole course of the fever. Thus 
the impurities of a prison are different from those of a hospital, and the 
insalubrious atmosphere of a camp must necessarily vary from that of a 
ship. Yet all these modifications of cause and effect are within what may 
strictly be called specific limits — varieties in the cause necessarily giving 
varieties in the effect. 

2. The inmates of prisons, hospitals, camps, and ships, differ from each 
other in the state of their constitutions. In the first there is simple and 
often insufficient diet, total want of exercise, filth, and confined air; in 
hospitals much exhalation from the bodies of the sick; in camps, intem- 
perance and exposure to cold and wet ; in ships similar exposure alternating 
with the breathing of confined air, loaded with foul exhalations from accu- 
mulations of their bilge, or from their timbers ; lastly, a diet which pro- 
duces or tends to produce a scorbutic diathesis. These different conditions 
of course predispose to corresponding variations in the type of the fever. 
For example, the soldier is likely to have pneumonia or bronchitis as a 
dangerous complication ; while the sailor may suffer disproportionately from 
the scorbutic deterioration of his blood. We see, then, the full value of 
the distinctions drawn from the different localities in which the fever is 
generated, and must admit that they are not an adequate ground on which 



INTERIOR VALLEY OF NORTH AMERICA. 465 

to construct different species. This conclusion is but a re-affirmation of 
that long since made by some of our standard writers. Thus, Dr. Trotter,* 
in speaking of what have " been called hospital, jail, camp, low, slow, 
nervous, putrid, and petechial fevers," says, " Any difference that has given 
rise to these names, in the nature of the fever, seems to have been more 
owing to the peculiarities of constitution, situation, climate, season, habits of 
life, &c, of the patient, than any real difference in the disease itself. We 
have seen often, among a number of men living together, the same infection 
produce a fever, with all the variety of symptoms with which authors have 
described fevers under these appellations/' 

II. Another attempted distinction is into synochus and typhus. The 
difference in the aspect of a patient laboring under the former in its early 
stages, and another patient laboring under the latter in its advanced stages, 
is certainly very great. But extended observation has conclusively shown 
that the two are in fact but different degrees or stages of the same fever. 
It is rare to see a case of typhus, so called, that does not in its commence- 
ment appear with the nosological characteristics of synochus; and all Euro- 
pean and American experience proves that, unchecked, the latter gradually 
assumes all the pathognomonic symptoms of the former. The extremes in 
the febrile range presented to us under these names, are indicated by the 
terms synocha and typhus gravior. The former, by the acuteness of its symp- 
toms, is closely allied to the true phlegmasiae; the latter is the most distant 
from them of any febrile affection. A synochus may commence as a 
synocha; a typhus mitior as a synochus, and a typhus gravior as a fully 
developed typhus mitior. To speak in figurative language, one spirit 
animates the whole — they have the same personal identity, but the external 
manifestations change, and the change is according to fixed laws — from 
symptoms simulating high inflammatory excitement to those which express 
an ataxic and adynamic condition. When the fever sets in with the symp- 
toms which characterize the typhous state, whether mild or malignant, the 
constitution of the patient, or a modification of the remote cause or causes, 
may be assumed as the explanation. Previous enfeeblement is, of course, 
unfavorable to the development of the ^wasi-inflammatory symptoms of 
synocha or synochus ; and a concentrated poison may so depress the vital 
energies of those in previous health, as to generate symptoms of a malignant 
character from the beginning. We see all this exemplified in scarlet fever. 
Synocha is well represented by certain cases of scarlatina anginosa, and 
typhus gravior by certain cases of scarlatina maligna. Indeed, these two 
varieties of scarlet fever differ as widely in their symptoms as the synocha 
and typhus gravior of the nosologists. Another equally instructive illus- 
tration may be drawn from autumnal fever; the difference in symptoms 
between an inflammatory remittent and a malignant or congestive remittent 

* Medicina Nautica, p. 252. London, 1797. 
vol. ii. 30 



466 THE PRINCIPAL DISEASES OF THE 

being even quite as great as that between the most intense synocha, and the 
most irregular and adynamic typhus. 

III. A particular symptom has been made the basis of an attempted 
classification. Some cases of continued fever are attended through a part of 
their course with maculae or an efflorescence, others are not. Hence, there 
are, prima facie, two species, eruptive and non-eruptive. But this division 
does not bear even a superficial scrutiny; for no one has seen an epidemic 
typhous in which no maculae appeared, nor one in which they were present 
in every case. Even in the same family, at the same time, they will appear 
on one patient and not on another, while the symptoms generally are iden- 
tical, and all the etiological or antecedent circumstances the same. How, 
then, can specific distinctions be founded on this symptom ? In the con- 
tinued fevers there is doubtless a tendency to the pathological state on 
which maculae depend ; but it does not follow that they will always appear. 
Whole epidemics of malignant scarlatina may pass away without having 
presented a single case of well-developed rash. Of this kind is the disease 
formerly described under the name of malignant, ulcerous, or gangrenous 
sore throat, many of which cases present not the slightest efflorescence; and 
still they belong to the same species with other highly eruptive cases. Even 
small-pox ranges from a few aborting pimples, up to the confluent multi- 
tudes which envelope the patient in a coat of pus. With these facts before 
us, may we not ask whether in all cases of continued fever which are not 
arrested before a certain stage, maculae are not to some extent present but 
escape detection? This, from analogy, may be affirmed; but it is not 
necessary to our present purpose that it should be established. 

IY. Passing by the division into maculated and immaculated, and admit- 
ting a spotted aspect of the skin to be common, if not constant in the con- 
tinued fevers, an attempt has been made to constitute two species, founded 
on the characteristic appearances of the spots themselves. This brings us 
to the proposed distinction into typhus and typhoid. The occurrence of 
exanthems or cutaneous spots in continued fevers, had been noted from the 
time of Fracastorius, in the early part of the sixteenth century,* and by 
Huxham, Hoffman, Pringle, Hildebrand, and other original observers, for 
three hundred years ; but, down to Louis, no writer, as far as I know, had 
found in the differences presented by the cutaneous affections the signs of 
specific differences in those fevers. They were generally designated by the 
term petechiae, and described as spots, or stigmata, varying in color from 
red to purple or black ; sometimes few and small, at other times numerous, 
and running into patches or vibices. Occasionally assuming the character 
of a rash or true efflorescence, they would rise slightly above the general 
surface, and be followed by an exfoliation. In some patients limited to the 
trunk of the body, in others they extended to the limbs also. Always of a 
brighter red when they occurred earlier in the fever, or when its character 

* Pringle's Obs. on Dis. of the Army, Part iii. ch. vii. 



INTERIOR VALLEY OF NORTH AMERICA. 467 

was less adynamic, they became darker with its progress, that is, with the 
increasing debility of solids, and deterioration of the blood. The patholo- 
gical doctrine of putridity of that fluid, which prevailed throughout the 
period of which I have spoken, was well fitted to direct the attention of 
physicians strongly upon the purple or smoky color of these maculae; but 
still there is sufficient evidence that spots of a much brighter red were often 
noticed. Thus, as far back as 1683, a petechial fever prevailed in Germany, 
which presented cases with " livid and yellowish petechias," and others " on 
whom the spots were few and red."* In 1780, Dr. Donald Monro described 
them as " small, distinct spots, of a reddish color," showing themselves in 
the same epidemic with other cases in which the "skin was marbled or varie- 
gated as in measles, but of a color more dull and lurid."')' Later still, 
Hildebrand speaks of the " red-spotted exanthematous eruption of typhus," 
and of " red ecchymoses," so small as not to be observed without care.f 
Observations, which belong more properly to the preseut time, have con- 
firmed those which have been cited, and established the fact, that in the 
epidemic reign of what appears from all the other symptoms to be one fever, 
maculae of every kind, from distinct red dots, or, in the language of Fracas- 
tori us, lenticular spots, to lurid or purple vibices, or a miliary rash, may 
and do occur. 

Now the celebrated Louis, and his followers, including two distinguished 
American observers, Dr. Jackson and Dr. Gerhard, have seized upon one of 
the varieties of this cutaneous affection, and under the name of the "rose- 
colored lenticular spots," endeavored to make it the sign of a fever specifi- 
cally distinct from that which presents a different aspect of the skin. I 
cannot concur in this classification. We do not understand what patholo- 
gical condition in the continued fevers tends to generate the various dottings 
of the skin, which a part of the cases present, but I cannot doubt, that it 
is essentially or specifically the same in all ; whether the cutaneous affec- 
tion appears in the form of rose-colored capillary congestions, purple ex- 
travasations, or miliary exanthems, followed by exfoliation of the cuticle. 
Indeed, if two species were to be formed by a reference to the maculae of 
the skin they should not be of the kind proposed, but founded on the dif- 
ference between the rose and purple spots on the one hand, and the pseudo- 
morbillous rash on the other ; for the latter affection manifestly differs more 
widely from both of them than they do from each other. The difference 
between a passive, punctate congestion of red blood, in the capillaries, 
and petechias formed by its escape into the cellular tissues, is not as great 
as that between those conditions and the papulae which rise so high as to 
roughen the skin and detach the cuticle. I am far from believing, however, 
that such a division into species should be made ; for in the same epidemic 
and even on the same patients, all these forms of maculae are sometimes 

* Hoffman's Syst. of Fract. part i. ch. ii. § 3. 

f Obs. on the Means of Preserving the Health of Soldiers, vol. i. p. 233. London, 1780. 

X Gross' Translation, p. 44. 



468 THE PRINCIPAL DISEASES OF THE 

commingled. The value of means of classification is still further reduced 
by the fact that even in the hospitals of Paris, where the rose-colored spots 
have been sought after with keenest vision, they have not been seen in more 
than three-fourths of the cases, while in the Interior Valley they are seldom 
seen at all. It has rarely happened to myself to see them in our indige- 
nous fevers, and Dr. Sutton, who has described an epidemic -which in other 
respects corresponds very well with the typhoid affection of Louis, and who 
made diligent search for them, declares that they were "an extremely rare 
occurrence."* On the whole, we may say that as yet the attempt to divide 
the continued fevers into species, that shall be designated by the appearance 
of the skin, has been a failure. 

Y. It has been proposed to make the presence or absence of contagion 
the ground of two distinct species of continued fever. But in the preced- 
ing chapter we have shown that epidemics may begin from local causes, and 
propagate themselves by coDtagion. It is also well known and has been 
especially observed in our Interior Valley, where the inhabitants are insu- 
lated, that cases which apparently could not have been produced by conta- 
gion, and others which apparently sprang from it, will co-exist, with symp- 
toms identically the same. Indeed, no respectable writer, as far as I know, 
has ventured to give the specific characters of contagious and non-contagious 
typhus. It is true, that certain symptoms, called malignant or putrid — great 
debility, dark petechia and a hemorrhagic tendency — are spoken of by some 
writers as resulting from the absorption of contagion into the blood ; but 
this is a petitio'princvpii. They are evidences of an energetic action of the 
remote cause, but do not enable us to decide whether that cause was a mias- 
ma or a contagion. All that we know of the latter in the continued fevers, 
proves that it is occasional, capricious, and unreliable ; that neither its pre- 
sence nor absence is indicated by the symptoms ; and that it is no better 
fitted for characterizing species than are the maculae, which have just been 
prouounced inadequate to that object. We may indeed say of it, as was said 
of them, that there may be in all continued fevers a capacity for secreting 
contagion ; but that in many the secretion does not take place. In like 
manner, when a tubercular diathesis is established, there is a potential capa- 
city in the system for the deposit of the heterologous matter in nearly all 
the tissues, as sometimes happens, though in many cases it is limited to 
the lungs. 

VI. Nervous and Putrid. — Many writers have divided the continued 
fevers into nervous and putrid. We must not reject this kind of division 
because we now disbelieve in putridity, for a vitiation of the blood is unde- 
niable. According to our predecessors the putrid deterioration of the blood 
was productive of offensive excretions, a fuliginous complexion, livid pete- 
chias and vibices, hemorrhages, and gangrenous predispositions; which of 
course became the pathognomonic symptoms of that species of fever; while 

* History of Typhoid Fever at Georgetown, Ky., p. 41. 



INTERIOR VALLEY OF NORTH AMERICA. 469 

the nervous was characterized, negatively, by the comparative absence of 
those symptoms, and positively by the full development of subsultus ten- 
dinum, delirium, and coma. It is a sufficient objection to this division to 
say, that these pathological states of the nervous system and the blood are 
present i.n varying proportions in every protracted case of continued fever, 
except when it is converted into a phlegmasia, and the fever is kept up by 
the inflammation of some organ. It may be added, that strongly marked 
cases of each variety occur very often in the same epidemic, and even iu 
the same family at the same time ; finally, that contagion and maculag have 
been ascribed to both. They cannot, therefore, be regarded as distinct 
species. 

VII. Division by Pathological Anatomy. — The latest attempt at 
the construction of species has been by the pathological anatomists. This 
is not the place to study the structural lesions found after death from con- 
tinued fever ; and I shall only refer to them so far as may be necessary for 
our present purpose. They have been made the basis of two species, cere- 
bral and abdominal. According to Clutterbuck and many other British 
writers, typhus is an inflammation of the brain. The physicians of France 
and Germany, granting this, favor the idea of another species, in which 
there is inflammation in the abdominal organs, according to some in the 
stomach and duodenum — of others, in the lower extremity of the ileum. In 
the former case the symptoms are in harmony with the cerebral disease; in 
the latter, with the abdominal. To this species they give various names, as 
typhus abdominalis, dothinenteritis, intestinal exanthem, and typhoid. 

In constructing species we must have reference both to the symptoms and 
the structural lesions. There must be a constancy of connection between 
them, as there is between loss of muscular power, insensibility, coma, slow 
pulse, and stertorous breathing in apoplexy, and the sanguineous engorge- 
ment or extravasations in the brain, as found on dissection after death ; or 
the hard and frequent pulse, hot skin, headache, contracted pupil, delirium, 
and coma vigil, of cerebritis, and the capillary hypera3mia, lymphatic adhe- 
sions, and serous effusions revealed by autopsy. 

Now we may take it as a fact that in continued fevers, this association of 
symptoms and lesions is far more loose and uncertain than in the diseases 
which have been named; for when the cerebral symptoms have been well 
developed, the brain after death has often presented but few lesions ; and 
the abdominal lesions have quite as often falsified the predictions made from 
the symptoms during life. Moreover, the organs of both cavities are often 
found in a state of lesion in the same subject, while in different members 
of one family in the same epidemic, the chief lesions have been found in 
the head of one victim, in the abdomen of another. It is equally well 
known that the lesions in continued fever are not limited to the cavities 
which have been named, but are found likewise in the chest ; and these are 
so frequent that if we constitute as species the other forms, we might con- 



470 THE PRINCIPAL DISEASES OP THE 

sistently establish a third — the thoracic or pulmonary. We should then 
have the cerebral or typhus mitior of the British writers — the abdominal 
typhus or typhoid affection of the French and German — and the pneumonia 
typhoides of the American. These designations are founded in nature and 
may be retained, but they should be understood to express only varieties or 
modifications of a siDgle species. In certain countries or classes of people, 
one variety may prevail for a time, in others, another — then, again, all may 
be present in the same town or family. Even the whole of these lesions 
are not unfrequently found in a single post-mortem examination. The truth 
is, that we must admit a constitutional, typhous diathesis, with varying 
localizations; and not specifically distinct, primary local inflammations, 
generating fever, as in the phlegmasia. If this be admitted, it follows as 
a corollary, that the labors of the Parisian school, have simply made us ac- 
quainted with a form of typhous not peculiar to their city, nor ever epidemic 
there, but sporadically prevalent among them for some time past : not abso- 
lutely, but relatively to other forms, more prevalent in that city than else- 
where. 

SECTION II. 

I. In the last section, I have endeavored to show that all the attempts to 
divide the continued or typhous fever into two or more distinct species, have 
been unsuccessful. I certainly so regard them ; but want of previous, does 
not bar future success; and we cannot affirm, that because distinguishing 
specific characters have not been found in this group, none exist. The time 
was when measles and scarlatina were described as one fever; and it may 
be, that what nosology has done for them,, may yet be done for the typhous 
fevers. Contemplated from any point which commands a view of the whole, 
they certainly present a diversity so great as to suggest different species; 
yet in this respect they are not without a parallel. In measles, the catarrh 
is sometimes absent, and the range of color in the exanthems is from ordi- 
nary to dark red. In scarlatina, we have a still greater diversity, some 
cases presenting no sore throat, others an inflammation of the fauces, with 
acute fever and extensive efflorescence; others, gangrene of the throat, and 
no eruption. In autumnal fever, we have even more varieties, many of 
which stand in striking contrast with each other, and prima facie, might 
claim (though unjustly), to be erected into distinct species. Remarks of 
the same kind are applicable to hysteria. In the original and admirable 
history of that malady, by Sydenham, we have a recognition of a great 
number and variety of morbid affections in different parts of the organism, 
out of which a thorough-going nosologist might construct almost as many 
species ; yet that great observer saw in them all a common specific patho- 
logical character, which he indicated by the terms " hysteric passion." 



INTERIOR VALLEY OF NORTH AMERICA. 471 

My own experience has long since assured me of the accuracy of his 
views. 

The range in variety is very different in different diseases. Thus epi- 
lepsy and tetanus present more uniformity than the nervous disease just 
mentioned; small-pox more than scarlatina; yellow fever more than autum- 
nal fever ; epidemic cholera more than dengue. In all this, types or modes 
of morbid action follow the same law as the organized bodies in which they 
occur. There are animals which preserve the same type with remarkable 
constancy, and are easily distinguished from cognate species of the same 
natural genus ; while other genera, as canis and felis, respectively present 
groups which set analysis at defiance. In botany the same thing is true. 
Thus while all the members of the genus quercus are strongly marked with 
specific characters, those of salix and vitis offer to the practical botanist a 
labor not unlike that presented to the nosologist by the typhous fevers. It 
is in all these cases the multiplication of approximating varieties, which 
embarrasses the labors of constructing species, as it is the diversity of symp- 
toms and lesions in the continued fevers which renders their classification 
so difficult. As the canon in natural history, is, or should be, that where 
the characters of a group equally require and oppose a division into distinct 
species, the division should not be made, so in nosology. And regarding 
the natural group of continued fevers as of this kind, I shall speak of them 
as constituting a single species, as I have spoken of periodical fevers. Still 
it may be convenient to employ many of the distinctive terms now in use, 
though some of these are manifestly improper, as for example, putrid, for 
the reason that putridity of the blood has not been shown, and stands 
opposed to all we know of the animal economy ; and typhoid, for the reason 
that by the views we have taken it is not applied to a fever resembling, but 
to an actual typhus fever. To the phrase abdominal or iliac typhus, there 
can be no objection, provided that in the use of this as well as all other epi- 
thets, varieties only and not species are indicated. All classification requires 
a nomenclature for varieties as well as species. Thus we speak of annual 
and biennial henbane, and of idiopathic, infantile, and traumatic tetanus. 



CHAPTER XII. 

SYMPTOMS OF THE CONTINUED OR TYPHOUS FEVERS. 

The different epidemics and subepidemics which have been described in 
Chapters II. and III., have given a general idea of the symptoms of the 
typhous fevers which prevail in the Interior Valley. It is true that all are 
imperfect as omitting many symptoms which are known to occur in those 
fevers, not less than in failing to present the order or succession of their de- 



472 THE PRINCIPAL DISEASES OF THE 

velopment. It is well known, however, that the order in which the symp- 
toms are developed in these fevers is neither constant nor uniform. Thus 
the cerebral symptoms may precede the abdominal, and contrariwise, the 
latter may be the first to occur; and it is equally well known that the vitia- 
tion of the blood may begin to manifest itself at an earlier or a later date, 
that the exanthems or the maculae may follow the same latitudinarian rule, 
and that the pulmonary complications may exist from the beginning or 
occur only in the latter stages. A tendency to this irregularity pervades all 
the varieties of typhous fever, and in some is so decided as to have suggested 
the term ataxic, to express the want of order. With these facts before me, 
as I am not engaged in a systematic, elementary work, I do not propose to 
go into a minute and extended detail of symptoms, but rather to select those 
which are of a governing character, and acknowledged to be pathognomonic 
of the different varieties. 



SECTION I. 

OF THE FORMING STAGE. 

I. Period of Incubation. — In cases of non-contagious sporadic typhous, 
it seldom happens that a remote cause can be recognized as having acted, 
and of course nothing can be said concerning the period of incubation. In 
epidemics, especially those of cities, the patients may have lived in insalu- 
brious localities or habitations, and have been therefore constantly exposed 
for some time to the impress of miasms; or they may every day have come 
into communication with those who could impart contagion, and in all such 
cases, the time when the morbid impression was made is undefinable. 

Our books, however, contain narratives which have a bearing on the ques- 
tion, and prove that the stage of incubation in continued fevers, as in the 
periodical, varies in length, through a range which separates them widely 
from the exanthemata. Thus there are well-attested cases of individuals 
having been seized immediately after being exposed to the offensive exhala- 
tions from the body or bedding of a fever patient, and a greater number in 
which the indisposition commenced in two or three days. On the other 
hand, there are facts which seem to show, that the period of incubation is 
sometimes extended through weeks or even months. Thus it is not uncom- 
mon to see Irish immigrants taken down with the fever several weeks after 
they have left the vessel which brought them over sea, in which they were 
exposed either to contagion or idio-miasm. 

We shall, perhaps, never know all the causes of these variations in the 
length of the period of incubation. When its duration is very short, we 
may conclude either that the remote cause was uncommonly concentrated and 
virulent, or the individual peculiarly impressible, or both. Again, protec- 
tion from, or exposure to exciting causes, undoubtedly affects the length of 



INTERIOR VALLEY OP NORTH AMERICA. 473 

the stage of incubation. These causes, which play an unimportant part, if, 
indeed, any part at all, in the true eruptive fevers, have much to do in the 
production of the typhous. When they are epidemic, many persons are 
affected by the poison, and made weak and ailing; but the disease does not 
advance to full development in all, unless exposure to cold and moisture, or 
to some other exciting or auxiliary cause, should come in aid of the first. 
In epidemic typhous of local origin, we may safely assume that the systems 
of the people within the locality are very generally impressed with the 
poison. There is a sort of epidemic incubation, which should be met by a 
circumspect avoidance of all auxiliary causes. The same thing is true of 
autumnal fever, yellow fever, and epidemic cholera, but not of the eruptive 
fevers, with which certain varieties of typhous have been so often affiliated. 
The greatly deferred period at which the fever may begin, after exposure to 
the remote cause, must not be forgotten. Doubtless, many cases of typhous 
which seemed to have arisen, as the expression is, spontaneously, were the 
offspring of unknown or forgotten exposure to idio-miasma or contagion 
some time before. 

There are facts which seem to indicate that the remote causes of some of 
the varieties of typhous are cumulative in their effects, and that a continued 
exposure is often necessary to the production of the fever. This would 
suggest the propriety of not permitting an individual to be long exposed to 
the insalubrious atmosphere, but replacing each by a successor. In this 
respect, again, the typhous fevers differ from the eruptive, which are gene- 
rally contracted by a single exposure to the contagion. I cannot doubt 
that exposure through the night to a contagions or miasmatic atmosphere, 
is more perilous than an equal exposure in the day. This may result from 
several causes, first, the more limited ventilation at night; second, the in- 
fluence of sleep in favoring the impress or absorption of the poison ; third, 
the auxiliary influence of fatigue and loss of sleep in many of those who 
watch with the sick. 

II. Stage of Development. — The onset of the continued fevers is 
marked by depression of the vital forces, not less than perversion of the 
functions of the body generally. In the inflammatory, known as synocha 
and synochus, and in the rapid and malignant forms, this period is brief. 
In the varieties represented by the typhus mitior of Cullen, and the typhoid 
of Louis, we may say, in the continued fevers generally, the forming stage 
is protracted, very commonly running on through many days, and, occa- 
sionally, for two or three weeks, the patient almost imperceptibly growing 
worse. If, during this period, we seek for an organ whose functions were 
disturbed before those of any other — an original seat of the disease — we 
are disappointed. From the commencement, much, if not the whole organ- 
ism, is found affected, though, as in the subsequent stages, very unequally. 

The tongue is covered more or less with a foul, white, or yellowish fur, 
but has not yet assumed a red color; the appetite, with a few exceptions, 



474 THE PRINCIPAL DISEASES OF THE 

is impaired or lost, and not unfrequently a sense of sinking is felt in the 
epigastrium, which, in malignant cases, is deep and threatening. Nausea 
is not uncommon, but vomiting does not often occur; and bile is seldom 
ejected, except in the latter part of summer or in autumn, when, after the 
impress of the heat of summer, the action of the liver is inordinate. In 
some instances, the bowels are torpid, in others, irritable ; in many there 
is diarrhoea, with offensive but not bilious discharges, except in the season 
of the periodical fevers, and then not in all cases. In fact, the secretory 
function of the liver is, in most instances, suspended or impaired. The 
pulse is reduced in force and fulness, and sometimes increased in frequency. 
The circulation in the extremities and skin is diminished, a pallid or dusky 
hue appears, the perspiration is diminished, and the heat of the surface 
reduced, with occasional rigors, especially along the spine. The functions 
of the brain are invariably reduced in their activity and energy. The 
muscular movements of animal life are feeble and unsteady ; the organs of 
sense lose much of their accustomed sensibility; the feelings are obtuse, 
and the intellectual functions enfeebled ; dull head and backache is com- 
mon ; finally, the sleep of the patient is dreamy, unquiet, and unrefreshing. 

If the disease be not arrested in this stage, all the symptoms increase ; 
but a reaction is at hand. This, however, in some cases is very slight, and 
the early death of the patient indicates that his disease has consisted chiefly 
of a prolonged first stage. 

In general, a deeper chilliness immediately precedes the stage of reaction ; 
but it never equals that which occurs in an ordinary intermittent. I have 
not seen it amount to " a shake." In the worst cases it is generally least. 
In our autumnal remittent fever, the initial chilliness is about the same as 
in the continued fevers ; but the two differ in this, that the chill may be 
repeated daily in a diminishing or increasing degree in the former, but is 
scarcely ever reproduced in the latter, except the patient have been exposed 
to the cause of periodical fever. 



SECTION II. 

STAGE OF EXCITEMENT. 

I. State of the Circulation. — The development of this stage out of 
the last presents much diversity. In the forms which have an affinity with 
the phlegmasise or phlogistic fevers, and are designated by the epithets 
synocha and synochus, the rise is rapid in proportion to the closeness of the 
affinity ; and, in many cases, the physician is doubtful whether he has not 
a true inflammation to deal with, especially when, on bleeding his patient, 
he has evidence, in the buffy coat, of an actual hyperinosis of the blood. 
The acute pain which is often present in different parts of the system in 
these cases, still further suggests the presence of inflammation. These 



INTERIOR VALLEY OF NORTH AMERICA. 475 

pains may cease under an antiphlogistic treatment, but the fever will remain, 
and its true character is then made manifest. Before, however, this dis- 
closure is made by the treatment, the pulse instructively suggests the nature 
of the fever. Increased in frequency perhaps to 120, and augmented in 
volume, its tension rarely exceeds that of health; and never, I think, 
amouuts to what is expressed by the term " hardness" in the phlegmasia. 
In the discriminative language of Mr. Hunter, it is a pulse of action rather 
than force ; of frequency more than momentum. Yet, without a careful 
attention to its compressibility, its true character may not be ascertained. 
"When, under depletion, it loses less in fulness than it does in frequency, 
the prognosis is favorable. On the other hand, and much oftener, blood- 
letting diminishes its volume, but augments its frequency; consequences 
which are inauspicious. Yet this does not take place in every case, for 
occasionally an inflammation is established in some organ during the early 
period of the stage of excitement, and then the pulse will be sustained, not, 
it is true, as in the primary phlegmasiae, but much better than when such 
inflammation is not set up; its supervention is, indeed, an evidence that a 
certain degree of inflammatory diathesis is present. 

The pulse in these varieties of continued fever is not the same throughout 
the twenty-four hours. A morning remission, or an afternoon or evening 
exacerbation, are generally obvious, especially in malarial localities. The 
abatement is greatest in the force and fulness, least in the frequency, of the 
pulse ; and without the last, no favorable prediction can be made. The 
greater the range between the remission and the exacerbation, the better is 
the prospect of a good issue. A full intermission may at length show itself. 

With the progress of time, the energy and fulness of the pulse gradually 
fail, but its frequency becomes greater, and thus a case which began as 
synocha, will, after the lapse of a week, more or less, present the pulse 
which belongs to the variety termed typhus mitior, to which we must now 
give attention. 

To distinguish between synochus and typhus mitior, in the beginning of 
many cases of the latter, is quite impracticable. It would be like the 
attempt to distinguish between states of the system identical in kind, but 
different in degree. At a certain stage of the departure downwards, from 
the most inflammatory form of continued fever, we come to that which is 
from the beginning denominated typhous. In this we have a pulse of 
greater feebleness, of reduced, or at least not increased fulness, and of 
augmented frequency. With the progress of the fever, these portentous 
qualities are augmented in many cases, and, sooner or later, a certain degree 
of unsteadiness or intermission occurs, which is always the evidence of an 
unfavorable progress. As a general fact, the earlier this faltering of the 
heart the worse is the prognosis. In certain protracted cases, which at last 
prove fatal, it may not occur for several weeks ; in those which end favor- 
ably, it seldom occurs at all. 



476 THE PRINCIPAL DISEASES OF THE 

In typhus gravior, or the malignant variety, which may end in death in 
a few days, the pulse of excitement can scarcely be said to have an exist- 
ence. The heart participates in the deep and sudden depression of the vital 
forces, and a full and bounding pulse is not developed; on the contrary, it is 
feeble and fluttering. From the suddenness with which this pathological state 
is induced, it might be hoped that after bloodletting the pulse would rise in 
energy and acquire greater steadiness, and this has happened; but in general 
the loss of blood is followed by increase of weakness in the heart. A pulse 
of this kind in the early period of the stage of excitement portends a short 
and fatal course of the fever. 

II. Of the Innervation. — Symptoms of disorder in the brain and 
nervous system of animal life show themselves in the stage of excitement as 
in the preceding stage of depression. Notwithstanding the increase of force 
in the circulation and action of the heart, which follows on the advance 
from one stage to the other, there is no true increase of voluntary power. 
On the other hand, the patient now takes to his bed, and is, in reference to 
locomotion, weaker than he was in the first stage. In the language of Dr. 
Rush, the excitement is concentrated in the bloodvessels, and withdrawn 
from the muscles. This condition of the muscles of locomotion is, how- 
ever, common in phlegmasia^, though in a degree less decided. 

We have already seen that in the forming stage the functions of the 
brain are impaired. They now become more decidedly morbid. In the 
exacerbations of the fever, generally ranging from noon till midnight, more 
or less delirium manifests itself; at first of an active kind, but sooner or 
later of a low and muttering character. That which prompts the patient 
to locomotion gives in general the worst indication. The morbid vigilance 
which is so often present in the phlegmasiae and in our autumnal remittent 
fever, is less common in our typhous fevers. On the contrary, at an early 
period in many, but not every case, a dull and drowsy condition arises. I 
have repeatedly seen it precede delirium, and, indeed, give the first unequi- 
vocal evidence of a typhous diathesis. With the progress of the fever it 
becomes more profound, but occasionally gives place to morbid vigilance, 
with wild delirium. 

- Another symptom equally characteristic of the typhous fever is subsultus 
tendinum, and the grasping at imaginary objects. These movements, 
almost confined to the upper extremities and the lips, often show themselves 
as early as coma or delirium, and are equally characteristic of these fevers. 
The union of the three, however slight may be their degree, establishes the 
diagnosis. Their increase shows the increasing gravity of the fever; their 
abatement as infallibly indicates its decline. The deep embarrassment of 
the brain, of which these symptoms are the offspring, is manifested in other 
modes. A certain degree of deafness, or a tinnitus aurium, is not unfre- 
quent, but the eye is more affected than the ear. Its expression is altered, 
and while reduced in most cases to dulness, sometimes becomes unnaturally 



INTERIOR VALLEY OF NORTH AMERICA. 477 

wild and staring. The pupils are in general preternaturally contracted; but 
now and then one or both may be dilated. A sanguineous congestion of 
the conjunctivae appears, and with the progress of the fever a mucous secre- 
tion exudes from between the lids. Both hearing and vision are occasionally- 
morbid, and the patient believes that he hears or sees frightful sounds, or 
objects which have no existence around him ; a condition which has been 
not unaptly compared by some of our physicians to that of the senses and 
imagination in delirium tremens. 

The cases of typhous which present this striking development of cerebral 
symptoms without diarrhoea, are generally regarded by our physicians as 
constituting the typhus mitior of Cullen and the British writers generally; 
and to this view there can be no objection, provided they mean a variety 
only, and not a distinct species. To view them otherwise, is to forget that 
these symptoms are all present, though in a mitigated degree, in every case 
of fever which can claim admission into the typhous group; that no case of 
fever, in which the whole are absent, can be with any propriety referred to 
that head. The true designation for such cases is cerebral typhus. 
, Pain is not among the prominent symptoms of the continued fevers, yet 
it is never entirely absent, and is sometimes severe. In the forming stage 
it generally occurs as a dull and heavy aching in the head, back, and limbs; 
but in the stage of excitement, it becomes more acute, and in some cases is 
severe, when it generates jactitation. When concentrated in the head, it 
may suggest inflammation of the cerebral membrane, especially when the 
state of the circulation may be in harmony with it. In many cases it is 
seated in the abdomen ; but never assumes the acuteness of that dependent 
on primary inflammation of the organs of that cavity. In a large number 
of cases it is only felt or complained of under pressure or percussion, and 
then most acutely in the epigastrium, or the right iliac region. It is a 
favorable sign for the patient to complain of pain, provided he can indicate 
its locality; but to moan as he lies untouched, or to complain under exami- 
nation, without a consciousness of the seat of his sufferings, shows a danger- 
ous affection of the brain. 

III. Symptoms in the Digestive System. — 1. The tongue, in the 
early periods of the stage of excitement, especially in cases which simulate 
the phlegmasia, presents the appearance which it wears in them. A white 
fur covers its surface generally, which is often more copious along the 
median line. Sometimes enlarged papillae project through it. From the 
beginning the moisture of the mouth is deficient. Much earlier than in the 
true inflammatory fevers, the white color begins to change to a dirty yellow 
or dead-leaf hue, the coating at the same time becoming drier. As it falls 
off near the point of the organ, the mucous membrane is found unnaturally 
red, and the same complexion extends round the edges. In many cases, 
the point of the organ becomes compressed laterally and somewhat swollen, 
so as to make a rude approach to a pyramidal form. The fur often dries on, 



478 THE PRINCIPAL DISEASES OF THE 

and seems to adhere to the mucous membrane, at the same time assuming a 
much darker color. In other cases it peels off, and the whole dorsum 
exhibits a raw, dark, and dry aspect, occasionally with transverse fissures. 
All experience has declared the kind of tongue here described to be emi- 
nently characteristic of a typhous diathesis. It is, indeed, one of the safest 
means of diagnosis, distinguishing those fevers, even in their early stages, 
from the pheginasiae on the one hand, and certain constitutional hysterical 
irritations on the other, which last are characterized by a pale, broad, and 
flabby tongue. The dark-red aspect of the organ is generally regarded as 
indicating a serious lesion of the mucous membrane below, as conclusive 
evidence of abdominal typhus. It is, doubtless, present in most cases of 
that kind ; but I have often seen it when the special symptoms of that 
variety were either absent, or few and very mild, and the signs of cerebral 
typhus were strongly marked. A slight retraction of the upper lip soon 
begins, and increases with the progress of the fever. The front teeth and 
gums become dry from exposure, and near the line of junction, a dark, 
tenacious matter, or inspissated sordes, collects upon the former, and becomes 
more considerable with the advance of the fever. 

2. The pharynx is sometimes red and generally dry. Now and then, 
there is pain, or inconvenience in deglutition. Being the seat of thirst, 
which throughout the stage of excitement is always urgent, it might be 
expected to show the appearance of sanguineous congestion. 

3. The gastric symptoms are not often very urgent. As a general but 
not invariable fact the appetite is destroyed. Nausea, or even full vomiting, 
with constant irritability of the stomach, characterize some cases, which at 
the same time present great epigastric tenderness, indicative of mucous 
inflammation. As in the preceding stage, bile, at least in considerable 
quantities, is seldom thrown up in this stage of the fever; and on the whole 
it may be said that the gastric symptoms are less constant and severe in our 
continued than our periodical fevers. 

4. The intestinal symptoms have attracted much attention. In some 
cases the bowels are torpid if cathartics be withheld, but readily pass into 
the opposite condition if they be administered. Constipation is generally 
regarded as an evidence of cerebral rather than intestinal complications; 
but it is now well known that constipation may be present when the bowels 
are the seat of serious lesion ; and on the other hand diarrhoea may exist 
without organic lesion. Of the two conditions constipation is the least por- 
tentous. The alvine discharges in this as in the preceding stages are seldom 
bilious ; except as far as a dirty greenish hue, sometimes present, may indi- 
cate bile. Occasionally they are dark, yet without blood. In the majority 
of cases they present a neutral aspect of sero-mucous and feculent matter, 
broken down and sending forth an abominable odor. When active purging 
has not been effected in the early stages, copious discharges of scybalae 
have occurred spontaneously in the more advanced. Now and then the 



INTERIOR VALLEY OF NORTH AMERICA. 479 

evacuations are dysenteric, when the two forms of disease are not blended 
in the same epidemic, a combination, which as we shall see hereafter, pre- 
sents great difficulty in the treatment. 

Peritoneal tenderness, and pain in the absence of pressure or percussion, 
are not present in all cases attended with intestinal lesion, but when pre- 
sent may be taken as evidence of its existence. These symptoms are not 
limited to the right iliac region, though much oftener found there than else- 
where. A tympanitic fulness of that region, and a gurgling sound under 
pressure from the movement of flatus, are regarded by Louis, Chomel, and 
others, as pathognomonic of disease in Peyer's glands ; but they certainly 
occur in some other abdominal affections ; and that they do not depend on 
that lesion exclusively is proved by their general absence in phthisis, which 
is accompanied by inflammation and ulceration of those glands. 

Throughout our Interior Valley, there is an increasing tendency in the 
profession, to refer all cases of continued fever which present a striking de- 
velopment of abdominal symptoms (especially when the cerebral are mild), 
to the head of typhoid fever. This is generally done without any distinct 
conception of the relation between typhus and typhoid. The aim of those 
who make the reference is simply to identify our fevers, with those of Paris. 
I need not here repeat, that the cases which present a striking display of 
intestinal symptoms, can with no propriety be erected into a distinct species; 
and if they could, the term typhoid would violate every rule of philosophi- 
cal nomenclature ; while if we regard the cases to which it is applied, as 
constituting a mere variety, it is equally objectionable, as involving no 
hypothesis, and simply indicating the most formidable localizations of the 
fever; the German phrase abdominal typhus, is every way preferable.* 

5. The symptoms of hepatic derangement, in most cases entirely absent, 
are seldom multiplied or striking. Scarcely one at any time indicates in- 
flammation in the liver. Of its reduced secretion, I have already spoken. 
In autumn, however, both throughout the Interior Valley and in Europe, 
biliary derangements, generating a sallow or jaundiced hue, have occasion- 
ally appeared in epidemic prevalence with those fevers. 

6. The symptoms of splenitis so rarely appear that I have not seen them 
in a single instance, but the organ, subject to enlargement, sometimes ac- 
quires a size which impairs the resonance of the lower portions of the left 
side of the thorax ; and might suggest a pulmonary complication. 

IV. In the respiratory apparatus. At an early stage of the fever the 
breath of the patient becomes peculiar and somewhat offensive. It may 
be that the exhalations from the skin contribute to the effect produced on 
the senses. The odor has often served me to some extent as a distinguish- 

* This deference to a celebrated name in a great European capital, by the physicians of a newly 
settled country is natural, and can scarcely be reproved ; but the writings of Louis alone have not se- 
cured to him this tribute of respect; for they have not been generally read by us. It is to our own 
Pnfessor Bartlett, the finished, elegant, and popular commentator of the French pathologist, more 
than to himself, that we should chiefly ascribe the currency which his views have obtained among us. 



480 THE PRINCIPAL DISEASES OF THE 

ing characteristic between typhous fevers on the one hand, and the pbleg- 
masise and remittent autumnal fevers on the other, which in the beginning 
are liable to be confounded. The ordinary symptoms of pulmonary lesion 
are in general absent or obscure. Many cases run their course without any 
serious affection of the lungs; but in others it occurs, and yet may not 
manifest itself by the ordinary symptoms of pain, stricture, dyspnoea, 
cough, and expectoration. In some instances it has only been revealed by 
& post-mortem inspection. This dumbness of the lungs under progressive 
disorganization, is generally ascribed to the lesion of the functions of the 
brain. According to the necroscopic researches of Andral and other patho- 
logists, the pleura is seldom affected, which may account, in part, for the 
absence of pain. A bronchial affection is more common, but pneumonic 
congestion is the usual lesion ; and should be detected by percussion and 
auscultation. A rust-colored sputum is not always expectorated in these 
cases, for in many the hyperaemia is rather passive than active, especially 
when the pulmonary affection begins at an advanced period of the fever. 
A slow and imperfect respiration, a feeble action of the heart, and the long- 
continued supine position of the patient, probably contribute mechanically 
to the production of the hyperaemia, and a pulmonary disorganization 
which does not always present the anatomical characters of true pneumonia. 
The earlier the pulmonary affection begins, the more obvious are its mani- 
festations. When it commences with the fever the disease properly takes 
on the name of pneumonia typhoides, or pulmonary typhous. In many por- 
tions of our Valley, the modification of continued fever we are now consider- 
ing, is known under the names of lung fever and winter fever. 

V. State op the Calorific Function. — The heat in the stage of ex- 
citement is generally high and sustained. It has been described as leaving 
in the hand, when applied for some time, a pungent sensation. Perhaps it 
would be more correct to say, that such a sensation has followed the appli- 
cation of the hand, for the purpose of ascertaining the temperature of the 
skin. From the difficulty in a new country of obtaining suitable thermome- 
ters, and of using them in private practice, I have not made experiments, 
nor have I met with any, on the typhous fevers of the Interior Valley. 

In London, Dr. Dimsdale made observations on twelve patients; the 
lowest heat, was 100° — the highest 105°— average, 102-2°.* Dr. Fordyce 
gives 105° as the maximum. f But Dr. Currie frequently found it 107°, 
and once as high as 109°.J 

The heat is not always in harmony with the energy of the circulation, 
for it may. be high when the pulse is feeble. It abates in the morning, but 
not in general to the standard of health — following a law of decrease and 
increase — not of intermission and reproduction. The heat of the head and 
trunk is always greater than that of the extremities. In many cases the 

* London Med. and Phys. Jour. vol. Ix. p. 206. 1803. f Third Dissertation on Fever. 

Z Med. Kep. on the Effects of Water. 



INTERIOR VALLEY OF NORTH AMERICA. 481 

feet are cold, while the head is hot — always an unfavorable sign. In cases 
accompanied with feeble reaction, the heat may not rise above the natural 
degree. In malignant and rapidly fatal cases, it sometimes continues re- 
duced below that degree ; except in the head and trunk of the body. 

There seems to be a propriety in placing hemorrhages and petechias 
under the same head. 

VI. Hemorrhagic and Petechial Phenomena. — Hemorrhage from 
the nose in the first days of excitement occasionally occurs, and is not 
ominous. Very rarely the epistaxis has been profuse. Hemorrhage from 
the bowels takes place in a considerable number of cases ; and is some- 
times decidedly copious. Occurring before the disease is far advanced, it 
may be followed by mitigation of the fever, but when the patient is much 
exhausted, his condition is made worse. I do not think that hemorrhage 
is of as frequent occurrence in our typhous fevers as we have seen it is in 
yellow fever ; yet it happens much oftener in them, than in our remittent 
autumnal fever ; and it is worthy of observation, that it seldom occurs in 
the latter, till they have reached a typhoid stage. In latter years, the 
maculated, petechial, and exanthematous appearances of the skin, have at- 
tracted great attention. In speaking on the classification of the continued 
fevers, this part of their symptomatology has been to some extent antici- 
pated. I think it may be received as a fact, that these cutaneous phenomena, 
in every form, are of less frequent occurrence in our Interior Valley than 
in Europe. Even there they cannot be ranked with the ever-present and 
essential nervous and cerebral symptoms. 

The simplest cutaneous appearance is the red puncture or dot, often so 
small as to escape observation. It depends on a congestion of the capilla- 
ries, equally limited in extent. The turgescence of the vessels is sometimes 
so great, as to produce an elevation which can be felt. Pressure will at 
first empty the vessels, but the blood immediately returns into them. At 
a more advanced stage it cannot be pressed out. These are the rose-colored 
spots of Louis, to which so much importance has been attached, as signifi- 
cant of a distinct species of typhous. The term petechiae has been applied 
to spots of the same kind, though in general of greater area, which exhibit 
a purplish or livid hue ; in malignant, or very advanced cases, a sooty or 
even black color. When of great size they are called vibices. Many of 
these spots are true hemorrhages. Their complexion shows the presence of 
venous, instead of arterial blood. They are doubtless, in many cases, the 
sign of deep, perhaps undetected pulmonary congestion, impeding the due 
aeration of the blood. A rash or papillary congestion constitutes another 
variety, which gives a roughness to the skin, and sometimes leads to an 
exfoliation of the cuticle. This efflorescence may be either of a bright or dark 
red; following in that respect the same law with the maculae or insulated 
spots. Occasionally the whole of these varieties will disappear, and reap- 
pear in the same attack of fever. They have all been seen at the same 

VOL. II. 31 



482 THE PRINCIPAL DISEASES OF THE 

time, or progressively on the same patient ; but more commonly, in the 
same epidemic one patient exhibits the petechial spots — another the rash ; 
and not unfrequently, epidemics follow the same rule. These various 
cutaneous affections appear much more on the trunk of the body than the 
extremities, and least of all on the face; thus differing widely from 
measles and small-pox, and conforming more to scarlatina. They vary from 
the whole, however, in not occurring at a definite period after the com- 
mencement of the fever. In referring to some authorities on this point it 
may be well to go back to the time when the theoretical views which have 
latterly prevailed, had not yet been suggested, in doing which we shall see, 
moreover, that all the varieties were long since observed. 

Huxham saw petechise appear from the fourth to the eleventh day; a 
miliary eruption from the seventh to the eleventh and still later. Pringle 
saw petechia of a " brighter or paler red, and sometimes of a livid color," 
on the breast, back, legs, and arms, as early as the fourth or fifth day, but 
sometimes not till the fourteenth.* Hoffman saw them appear on the fourth, 
fifth, or seventh day. Monro on the fourth, fifth, sixth, or seventh day ; 
seldom after the eleventh or twelfth. Blane in the latter stages only ; Trot- 
ter at different periods of the disease. Hildenbrand describes an "ex- 
anthematous eruption" as occurring about the fourth day. Of later writers, 
Cheyne saw " minute, purple stigmata, or the florid, marbled efflorescence," 
without elevation of the cuticle, about the fourth or fifth day. Dr. Barker 
saw a "morbillous efflorescence" appear from the fifth to the seventh day. 
Dr. Pickells saw petechial, freckled, mottled, or morbillous appearance 
generally beginning about the fourth or fifth day. 

To come to later authors, Louis did not see rose-colored lenticular spots 
occur earlier than the sixth day j a greater number appeared on the tenth ; 
in some patients they appeared between the twentieth and thirtieth, and in 
one not till the thirty-third. Chomel saw them occur from the sixth to the 
thirty-seventh day. Andral "most frequently saw them appear in the 
middle of the fever, sometimes towards the end, and even during conva- 
lescence; very seldom from the commencement." Dr. Gerhard saw the 
rash appear about the third day — the rose-colored spots a little later. Dr. 
Sutton saw the latter occur in the second week of the fever. The duration 
of the cutaneous affection is as irregular and various as its time of beginning. 

I have already expressed the opinion, that we cannot construct different 
species of continued fever, by the guidance of the cutaneous affections, yet 
they may be advantageously studied in connection with other symptoms, — as 
for example, have the rose-colored petechias any peculiar relation to abdo- 
minal typhus, the livid to pulmonary typhus, and the exanthematous to 
the cerebral ? When, moreover, the petechia are unusually numerous and 
livid, as happens in some epidemics, they may be appropriately called 
petechial. 

* Rush's Pringle, p. 2G2. 



INTERIOR VALLEY OF NORTH AMERICA. 483 

Sudamina are less constant in their occurrence than the cutaneous affec- 
tions which have been described; yet they occur much oftener in the 
typhous than our autumnal fevers. They appear in all the varieties of the 
former, and may coexist with every form of petechias and exanthema which 
has been described. They afford no aid to special diagnosis, nor do they 
assist us in prognosis. "When the hot regimen was in vogue, they seem to 
have appeared more frequently than since a better treatment has been 
employed. 



SECTION III. 

PROGRESS AND TERMINATION OF THE FEVER. 

I. The typhous fevers are indefinitely self-limited, and run their course 
in periods varying from two or three days to as many months. This might 
lead to the conclusion, that distinct species have been nosologically fused 
into one, did we not know that the same remark is applicable to our autum- 
nal fevers. In both, however, the early termination, no treatment being 
employed, is generally in death. 

II. The symptoms which have been narrated, present us with the pheno- 
mena of these fevers when fully established, which on the whole constitute 
their phenomena throughout. When tending to a fatal termination, these 
symptoms become graver; when a favorable issue is in store, a gradual ame- 
lioration occurs. 

III. In the malignant, petechial, or syncopal typhus, the stage of excite- 
ment is a failure. A full reaction does not take place. The innervation is 
as it were blighted; the enfeebled heart fails to supply the brain and other 
vital organs with the requisite quantity of blood, and the lungs do not ade- 
quately aerate that which is sent through them ; the heat and sensibility of 
the skin are impaired, and in many cases petechiae and vibices, before absent, 
now make their appearance ; a deep sense of oppression prevails in the organs 
of the great cavities ; sometimes there is intense neuralgic or non-inflamma- 
tory headache ; delirium and coma, with spasmodic actions of the muscles, su- 
pervene ; dyspnoea and sighing show the oppressed state of the lungs and heart ; 
the stomach is torpid or extremely irritable, and the bowels are inactive or 
affected with profuse watery diarrhoea. Cold perspirations, involuntary stools, 
insensibility and complete exhaustion, speedily follow, and death closes the 
scene. In various parts of the temperate portions of the Interior Valley, this 
atonic and adynamic variety of typhus has now and then shown itself, to a 
limited extent, chiefly in the winter season. 

IV. But the ordinary progress and termination of our typhous fevers is 
widely different from these. The stage of excitement, once established, 
continues with but little variation, except that which results from a gradual 
ingravesCence of the symptoms, especially the cerebral. Thus the subsultus 



484 THE PRINCIPAL DISEASES OF THE 

tendinum, and muscular debility, the delirium, coma, and insensibility 
suffer constant augmentation, the pulse becomes inordinately frequent, irre- 
gular, and feeble, the diarrhoea often increases, and the discharges always 
become more vitiated and offensive; the gurgling under abdominal pressure 
increases, and sometimes a general tympanitis supervenes ; now and then 
a profuse discharge of black blood from the bowels still farther exhausts the 
vital powers; urine is still secreted, but the insensible bladder allows it 
to accumulate and be retained; the heat of the surface is apt to fail in 
the extremities, and partial perspirations, generally on the upper part 
of the body, appear ; the petechia assume a still duskier and more 
ecchymosed aspect; the tongue, which the patient can no longer protrude, 
assumes a darker and drier hue; the retraction of the upper lip and the 
dryness and foulness of the exposed teeth, become greater; finally, the well- 
known and ominous sliding down in bed, clammy or cold watery sweats, sus- 
pended deglutition, hiccough, and the involuntary discharge of liquid faeces, 
exhaling an intolerable odor, and the profound stupor of the patient, fore- 
shadow his impending death, to be followed by early putrefaction of the body. 

V. But all cases of typhus which advance in the manner here pointed 
out, to a stage of extreme severity, do not terminate fatally. A sudden 
abatement, " a turn in the fever," to employ the popular phrase, a kind of 
crisis, sometimes takes place, and a returning normal state of the functions 
generally becomes manifest about the same time in the whole. But what 
is the period at which a fatal or a favorable ending takes place ? It is cer- 
tainly extremely various. If we take a week as the minimum, we shall 
find but few cases which conform to it ; a far greater number run on to a 
fortnight ; perhaps a greater number still to three weeks; while many reach 
a month. As a general fact, when the disease extends beyond that period, 
it undergoes, as we shall presently see, some degree of modification, both in 
its symptoms and mode of termination. 

I have spoken of weeks, but neither the histories of our continued fevers 
nor those of Europe, show that in terminating, they observe hebdomadal 
periods, or any of the critical days so much insisted upon by the ancient, 
and some modern writers. It is possible that this may be owing to the 
more active and perturbating treatment, which in this country especially 
prevails in modern times. Yet how is it possible to count the days of a 
fever which generally begins in a stealthy and a gradual manner, and often 
allows the patient to keep on his feet for two or three weeks, after the 
forming stage of the disease has actually set in. We can speak correctly of 
the duration of the eruptive fevers from the beginning, because this is not 
the case with them, because their onset is generally sudden, and still fur- 
ther, for the reason that new symptoms arise, and earlier ones disappear, to 
constitute and mark successive and tolerably uniform stadia; all of which 
is wanting in the group of fevers we are now studying. 

VI. Continued fevers, which extend beyond a month, may still terminate 



INTERIOR VALLEY OF NORTH AMERICA. 485 

in the mode which has been pointed out ; but, in general, they undergo 
some change of symptoms, and end with different phenomena. The change 
very commonly indicates an abatement in the constitutional symptoms, 
those manifested in the innervation and circulation, while certain local 
symptoms remain unabated, or even become more intense. Some great 
organ, the chief seat of torpor, congestion, or inflammation, is unable to 
recover its normal condition, and now, by its reaction upon the rest, retards 
their restoration, and thus the fever, in a modified and reduced degree, is 
kept up. When the disease in the suffering organ is subdued, convalescence 
advances favorably, and the recovery is complete ; but should the visceral 
affection prove incurable, death at last occurs, preceded by symptoms con- 
siderably different from those of an earlier termination, as well as from each 
other. 

The organs which suffer most are the brain, the bowels, the lungs, and 
the spleen. 

1. Of (lie Brain. — If this organ, at an earlier stage of the fever, often 
show signs of real or supposed acute inflammation, such are not the pheno- 
mena which it now exhibits ; yet they may sometimes depend on a low 
or subacute inflammation. Those which are most common, are slight sub- 
sultus or muscular irregularity, occasional dull headache, with a sense of 
heaviness or constriction, more or less drowsiness, a slight delirium at 
night, with or without morbid vigilauce, a contracted or dilated condition 
of the pupils, and a dulness or imbecility of miud, which sometimes con- 
tinues after the patient has begun to walk about. In a family in which I 
saw one individual affected in the manner last mentioned, another passed 
through a short period of actual insanity. When such cases prove fatal, 
the mode of death is nearly the same with that from original inflammation 
of the brain. 

2. Of the Bowels. — Many protracted cases are complicated with obstinate 
diarrhoea, and a continued excretion of morbid matters. The liver is gene- 
rally torpid, as appears from the prevailing absence of bile; and this may 
sometimes keep up the diarrhoea; oftener, however, it depends on glandular 
lesion of the ileum, which frequently maintains the tenderness and gurgling 
which were present in the right iliac region at an earlier period of the fever. 
The cerebral symptoms may continue, but in a greatly mitigated degree. 
Although the appetite of the patient may be partially restored, he continues 
emaciated. An evening exacerbation of the fever remains. The tongue 
may, to some extent, recover its moisture, but is apt to remain red and 
smooth on the surface. The convalescence from this condition is generally 
slow ; the mode of death may be twofold : first, by a gradual wasting away 
to an exhaustion of the vital forces ; second, by the sudden supervention of 
abdominal pain and tenderness, with flatulence, irritability of the stomach, 
great feebleness and frequency of the pulse, anxiety, rigors, and extreme 
prostration — symptoms sufficiently indicative of peritoneal irritation and 



486 THE PRINCIPAL DISEASES OF THE 

inflammation, the result of intestinal perforation, and the escape of the con- 
tents of the bowels into the cavity of the peritoneum. The duration of 
these symptoms is various, according to the area of the opening. In many 
cases, death occurs within twenty-four hours ', others are more protracted, 
and when the aperture is small, and early adhesive inflammation closes 
it up, recovery may still take place. In some instances the original fever 
may so far cease that the patient will leave his bed, ride out, and regard 
himself as nearly well, when the symptoms of a fatal termination may be 
suddenly and unexpectedly developed. 

3. In the Lungs. — We have reason to believe that many protracted cases 
of continued fever are complicated with occult pneumonia, or pulmonary 
congestion. In such cases the cerebral and abdominal symptoms may abate 
so far that full convalescence is anticipated, but not realized. Percussion 
and auscultation may detect that which was but equivocally indicated by 
the rational symptoms. They, however, may at length be more fully deve- 
loped, and in proportion as this takes place, the original febrile symptoms 
disappear, to be preceded by evening hectical paroxysms, followed by 
morning sweats. Kecovery may take place under remedies addressed to the 
suffering organ; but not unfrequently the patient gradually sinks under an 
imitative phthisis. In some cases, during the fever, a deposit of tubercular 
matter is effected, and true phthisis ensues. We know this in the Interior 
Valley by the symptoms and physical signs, and Andral has ascertained it 
by dissection in the hospitals of Paris. 

4. In the Spleen. — I have already referred to the softening and enlarge- 
ment of the spleen in the typhous fevers, and the difficulty of detecting 
those lesions during life. It is impossible to say how far they may contri- 
bute to prolong fever ; but from analogy, I am disposed to assign to them a 
positive influence in that way. We are familiar with the fact that the same, 
or a similar affection of that organ, from autumnal fever, retards recovery, 
and favors relapses; and why should it not exert a like effect in the con- 
tinued fevers ? Why may we not assume that some protracted cases, in 
which, day after day, we are expecting to see a decided convalescence begin, 
are maintained by this condition of the spleen ? 



CHAPTER XIII. 

PATHOLOGICAL ANATOMY OP TYPHOUS FEVERS. 

[The materials for the construction of this chapter, in the handwriting of 
the author, are extremely fragmentary ; much of the original manuscript 
being probably lost or mislaid, and what remains bearing evidence of having 
been intended to be rewritten. — Ed.] 

I. The Brain and its Membranes. — 1. Effusion of Coagulable 



INTERIOR VALLEY OF NORTH AMERICA. 487 

Lymph. — The solid contents of the cranium present but few traces of in- 
flammation, if we insist on the presence of effusions of coagulable lymph as 
the evidence of that pathological state j and this is true of the continued 
fevers, which have received the name of typhus, not less than of those called 
typhoid. In the Dublin epidemic of 1813, '14, and '15, Dr. Percival seems 
not to have discovered such effusions.* In that of 1817-18, according to 
Dr. Macartney, they were equally rare.f Dr. Reid, however, found "various 
adhesions" of the membranes. J In the epidemic of 1826, Mr. Jacob made 
six dissections, in one of which he found traces of effused lymph. § In the 
fever of the same year at Edinburgh, Dr. Alison made dissections, but says 
nothing of lymphatic effusions. || In the fever of the same city, from 1836 
to 1839, Dr. Reid examined the brain in forty-three cases ; but in his report 
of the morbid appearances, says nothing of such effusions. ^f In ten dissec- 
tions, made by Dr. West in St. Bartholomew's Hospital, London, slight opacity 
of the arachnoid was found in two.** In Paris, Louis examined the brains 
of forty-six patients dead of what he calls typhoid fever, and found effusion 
of lymph in two only.*f"|" In the same city, Andral did not find such effu- 
sions in more than one out of seventy-one cases of the same fever.Q In 
Philadelphia, Dr. Gerhard examined the bodies of many who died of what 
he calls typhus, and gives the history of six, none of which presented any 
traces of effused lymph. §§ From these researches, we see that in different 
and distant places, typhous fevers of various kinds terminate fatally, with- 
out being accompanied, in a great majority of cases, with effusions, affording 
the only indubitable evidences of previous inflammation, if we except 
purulent ones. 

2. Suppuration. — This morbid change is even still more rare than the 
preceding one. 

3. Sanguineous Congestion. — This is so common a morbid appearance, 
that it seems unnecessary to multiply authorities in detail. It has been 
found in the fevers denominated typhus and typhoid, in England, Ireland, 
Scotland, France, and the United States. In some cases it has been chiefly 
observed in the sinuses and veins, in others in the capillaries, sometimes 
in the pia mater, at others in the subarachnoid cellular tissue, the convolu- 
tions, and even the white matter, to which they have imparted a rose-color. 
In a few cases, limited extravasations bave taken place. 

4. Serous Effusions. — These, as a consequence of the congestion just 
named, although not invariably present, are very commonly met with. In 
general, they are not very copious. Sometimes they are subarachnoid, in 
others ventricular. Like the congestions, they are found after death in 
all the varieties of typhous fever. 

* Trans, of Assoc, of Fellows and Licentiates of King's and Queen's Coll. vol. i. p. 303. 

t Ibid. vol. ii. p. 574. + Ibid. vol. iii. p. 29. § Ibid. vol. v. p. 512. 

|| Edin. Med. and Surg. J. vol. xxviii. p. 233. \\ Ibid. vol. Iii. p. 448. 

** Ibid. vol. 1. p. 131. tt Researches on Typ. Fever, vol. i. p. 318. 

ft Clinical Med. vol. i. p. 185 (Amer. Ed.). \\ Amer. Jour. vol. xix. p. 303. 



488 THE PRINCIPAL DISEASES OF THE 

Are these congestions and effusions to be taken as evidences of inflamma- 
tion ? I cannot so regard them. The general absence of fibrinous and 
purulent effusion, of hyperinosis of the blood, and of softening or indura- 
tion, the great topographical extent of the congestion and its equability, 
the predominance in many cases of venous blood, and the almost constant 
presence of serous effusion, the legitimate product of simple congestion, all 
stand opposed to the conclusion that these hyperemias indicate previous 
inflammatory action. 

I come then to the conclusion, first, that although inflammation of the 
brain may sometimes be set up in the progress of all the varieties of con- 
tinued fever, none of them are to be regarded as primary phlegmasiae of 
that organ or its meninges ; second, that all the varieties are in many cases 
productive of simple congestions and consequent serous effusions. 

Dr. Clutterbuck, if I am not mistaken, was the first writer who attempted 
to identify the typhous fevers with primary cerebral inflammation. The 
failure of an antiphlogistic treatment to arrest them, had already, dejure 
if not de facto, proved his speculation incorrect, when pathological anatomy 
confirmed the conclusions derived from therapeutics. Even allowing all 
the sanguineous congestions to be received in evidence of inflammation, 
these conclusions must still be regarded as legitimate, since in numerous 
fatal cases of the fevers we are considering, the absence of such congestion 
proves that there could have been no inflammation. 

The quotations which have been made, let it be observed, refer to all the 
modifications of typhous fever ; as far as the morbid anatomy of the brain 
can speak, therefore, it pronounces them but varieties of one disease. It 
does not, in fact, announce that cerebral lesions are more common and ex- 
tensive in the fever denominated typhus than in that lately called typhoid, 
but apart from the question of degree, it assures us that they are the same 
in kind. 

II. In the Thoracic Yiscera. — 1. Lungs. — In the continued fever of 
Paris, according to Andral, the bronchial membrane and pleura are gene- 
rally sound. In a number of cases, the parenchyma of the lungs had 
become impervious to air, and presented a brown or livid red color and 
pulpy consistence, resembling a softened spleen. In some cases, the more 
unequivocal signs of pneumonia were present. 

In 15 out of 43 cases examined by Dr. Reid in Edinburgh, the lungs 
were normal. In 10 out of 23 subjects, the posterior part of the lungs was 
in a state of congestion, to such a degree as to. sink in water; yet that 
pathologist did not observe the granular aspect so characteristic of inflam- 
mation. In several, the organ was cedematous; in one case only did he 
observe what he regarded as evidences of true pneumonia. 

In about one-third of the subjects examined by Louis, the lungs were 
natural. In many of the subjects which presented pulmonary lesion, the 
anterior and upper portions of the lung were commonly sound. The lower 



INTERIOR VALLEY OF NORTH AMERICA. 489 

and posterior presented a bluish-red color, were destitute of air, sank in 
water, on incision gave out under pressure a great quantity of thick, red 
liquid, but afterwards displayed no granulated aspect of hepatization, were 
not friable but resistent to the finger, presenting a lesion which that dis- 
tinguished pathologist very justly regarded as distinct from inflammation, 
and to which he gave the name of " splenification." In a considerable 
number of cases, however, he found manifest inflammation, nearly always 
limited to a small part of the organ, and productive of hepatization. These 
two lesions he found to exist in inverse proportions. In some subjects 
there were small abscesses. 

Dr. Gerhard (loco citato'), in his dissections of those who died of " typhus 
fever" in the Philadelphia epidemic of 1836, found the lungs in the same 
condition that Louis found them in the " typhoid affection" of Paris. 

Both these authors, and most others except Andral, have more or less 
frequently seen congestions of the respiratory mucous membrane. 

The observations of Dr. West, of London, on the condition of the lungs 
in those who died of " typhous exanthemations," agree with those of Louis. 

As additional facts would not change the premises materially, we may 
safely say that the lungs, like the brain, do not afford much evidence of 
inflammation. That such does sometimes occur is certainly true; but the 
lesion characteristic of the fevers under consideration is simple congestion 
without fibrinous effusion ; and the morbid appearances are substantially the 
same in the fevers of Edinburgh, London, Paris, and Philadelphia. All ob- 
servers concur in representing that pulmonary lesions do not in general exist 
from the beginning of continued fevers, but insidiously supervene during 
their progress, being, in fact, like those of the brain, secondary affections. 

2. Heart. — Dr. Gerhard found the heart softened in three cases, several 
ounces of bloody serum in the pericardium in one, one ounce of blood in 
another. Dr. West rarely found any affection of heart or pericardium, 
except some increased secretion in the latter. 

In ninety-eight cases, Andral found traces of lesion in but thirteen ; in 
two of these, softening ; in some, pallor and flabbiness ; in none, unusual 
red tints. 

In the forty-six cases reported by Louis, there was less consistence than 
natural in twenty-four cases ; in seven probably within the limits of sound- 
ness, leaving seventeen, or more than a third, affected with softening. The 
heart was also paler and drier than usual. 

Dr. Reid reports the heart sound in all but three out of forty-three, and 
in these the lesion was of old standing. 

We may state that on the whole the heart is less frequently affected than 
the lungs j the lesions observed are by no means the result of any preceding 
inflammatory action, and are of the same kind in the fevers of different 
countries. 

III. Abdominal Organs. — 1. Stomach. — Of forty-one cases, Dr. Reid 



490 THE PRINCIPAL DISEASES OF THE 

found this organ normal in thirty-one. In four there was thickening of 
the mucous membrane, with amammelonated appearance. In one, numerous 
rounded superficial depressions. In three, signs of softening from the 
action of the gastric juice ; in one, the redness of congestion. 

In six dissections, Mr. Jacob, of Dublin, found evidences of congestion 
of the mucous membrane of the stomach in two, patches of extravasation 
in one. 

M. Louis found softening and thinning of the mucous membrane in nine 
cases out of forty-six, it being healthy in thirteen. Simple softening was 
found in a much larger proportion. The color was generally a mixture of 
red and gray. A mammelonated state of the membrane existed in thirteen 
subjects, generally complicated with softening; and there was commonly con- 
gestion in the neighborhood of the mammelonated parts. These appearances 
were most frequently found in the bodies of those who had died early in 
the disease. Louis does not regard these lesions as peculiar to typhoid 
fever, having found them in nearly the same proportions in other acute 
diseases. 

In several cases, Andral found no appreciable lesion ; in a greater number 
red spots, or a general slight injection of the mucous membrane; in a few, 
thickening of the membrane ; in a greater number, softening, with a white, 
gray, brown, or red color. In some there were ecchymosed spots, in some 
ulceration. Andral thinks these appearances common in other diseases, 
and that but few of them are caused by inflammation. 

Dr. West found the stomach healthy in three out of ten; in two there 
were lesions of old standing ; in three congestion and softening ; in one 
universal rose-color, with ecchymoses near the cardia. 

Dr. G-erhard found softening of the mucous membrane, in one case ex- 
tending to all the coats in the cardiac portion ; and, in some cases, a more 
or less marked and deep slate color. For the rest, he agrees witoh the au- 
thorities already quoted. 

2. Duodenum. — In eight out of twenty-two subjects, Louis found the 
duodenum normal ; in other cases it presented evidences of congestion, 
softening, enlargement of the small glands near the pylorus, or small ulcers. 
He remarks that such appearances are not uncommon in those dead of 
other diseases. 

Andral " seldom found the duodenum affected." 

3. Small Intestines. — According to Dr. Reid of Edinburgh, of forty-one 
cases in which autopsy was performed, the glands of Peyer were u apparent 
and distinctly defined" in twenty-four; in six barely visible ; in eleven not 
apparent ; in four, -the solitary glands near the lower end of the ileum were 
also " distinctly visible." In all such cases they were of a bluish or grayish 
color, dotted over with dark spots. In four cases only were they distinctly 
elevated. In two only was there any appearance of ulceration of the mem- 
brane, but in some there was ulceration of the solitary glands. 



INTERIOR VALLEY OF NORTH AMERICA. 491 

Of 101 cases examined by Dr. Home, from 1833 to 1837, the elliptic 
patches were distinct and enlarged in twenty-seven, in seven there was 
ulceration, in two perforation. 

Dr. Goodwin, Jr., in ten dissections found elevation and ulceration of 
Peyer's and Brunner's glands in all, perforation in four. 

Dr. Perry, of Glasgow, found lesion of the glands of Peyer in a sixth 
part of those who died of the fever in that city.* 

According to Louis, the mucous membrane of the small intestines was 
white in thirteen cases out of forty-six, and the proportion was greatest 
among those who died earliest, being gray in eleven that died at a later 
period. In fifteen dying in all stages of the fever indiscriminately, it was 
red; in four cases tinged yellow by infiltration of bile. It had a natural 
consistence in nine cases, being more or less softened in all the rest. 

In the whole of the forty-six cases, the glands of Peyer were more or 
less affected, and the mucous membrane often unsound. In the first stage 
of morbid alteration they were but slightly elevated, being of a faint rose- 
color, the grayish points indicating orifices having disappeared. Advancing, 
they assumed a granulated appearance, and showed the orifices of the crypts 
open. To this succeeded a redder, larger, and softer condition, and finally 
ulceration was established. In eight out of the forty-six, perforation had 
taken place. All these different stages were occasionally presented in the 
same individual, making it appear that the elliptical patches do not become 
affected simultaneously but successively. 

Louis found the solitary glands more or less affected in twelve cases of 
the forty-six, always near the coeeum. They were generally flattened and 
white, though sometimes of a ruddy or gray color. In some cases they 
were ulcerated. 

Andral speaks of the small intestine as sometimes normal, though in 
some cases there was vascular injection of the lower part of the ileum, and 
sometimes the villi only were so affected. 

He has reported twenty-seven cases with autopsies of what he regards as 
" dothien-enteritis," or " typhoid affection." Of these, seven could not, 
from their symptoms, claim to be regarded as typhous, yet a lesion of 
Peyer's glands was found in all. These are Nos. 1, 2, 7, 8, 9, 10, and 11. 
On the other hand, he has given many cases in which typhous symptoms 
were present without lesion of the elliptical patches. In six of these there 
were abdominal symptoms, in three, abdominal maculae. 

4. Large Intestines. — [The manuscript materials for the further construc- 
tion of this chapter are entirely wanting. Not having access to all the 
sources whence the author derived the materials already incorporated in 
the text, the editor adds the following concise statement for complete- 
ness' sake. 

The morbid appearances presented on post-mortem examination of the 

* Edin. Med. and Surg. Journ. for Jan. 1836. 



492 THE PRINCIPAL DISEASES OF THE 

large intestine, are analogous to those found in the small ; namely, an ab- 
sence of all lesion in some cases, changes in the color of the mucous mem- 
brane, especially reddening, thickening, or softening in others. In cases 
terminating at a late period of the disease, ulcerations, more particularly 
about the ccecum ; in rarer cases, perforation. 

5. Mesenteric Glands. — These are found sometimes healthy, sometimes 
enlarged, or enlarged and indurated, or softened; very rarely presenting 
points of purulent deposition. All authorities agree that the glands nearest 
the coecum are those principally affected. This has been supposed to be 
in consequence of a prior affection of the follicles, but there is a lack of 
evidence to prove any necessary dependence of the former on the latter. 

It is generally allowed that there exists no invariable relation between 
the symptoms of special affections of the digestive apparatus and the morbid 
appearances on post-mortem examination, extensive lesions having been 
wholly unrevealed by such symptoms; nor are any of the pathological 
changes observed peculiar to typhous fevers, or of constant occurrence in 
them. 

6. Liver. — There is a less amount of morbid change observed in the liver 
than in the stomach and bowels, besides which it is not so frequently found 
diseased at all. It is sometimes paler, and of a drier appearance and feel, 
more rarely darker, redder, more full of blood, sometimes softened. The 
bile is either healthy, reddish, greenish, abundant, or thick, dark, grumous, 
less abundant, neither liver or bile presenting anything peculiar to typhous 
fevers, or not common in many other disorders. 

7. Spleen. — This organ presents more commonly, but by no means inva- 
riably, morbid appearances. Enlargement and softening are the most fre- 
quently observed departures from a healthy condition. The softening is 
sometimes so extreme, that the organ is almost pulpy in its consistence. 
It is generally darker than natural, occasionally almost black. Dr. Gerhard 
found the spleen normal in one-half of his cases, Louis four out of forty-six. 

8. The Pancreas and Genito- Urinary apparatus. — These present only 
occasional lesions, being generally found in a healthy state. 

As each of the organs contained in the abdominal cavity is occasionally 
found healthy, none of the lesions described can be considered essentially 
connected with typhous fever, while those most characteristic of that form 
of disease are the affections of the elliptic plates, and the softening of the 
spleen. 

IV. The Blood. — This fluid is almost constantly changed in its physical 
characters. Huss found it " dissolved" in forty-seven out of fifty-four cases ; 
Chomel completely so in fifteen out of thirty cases, with dark coagula in 
nine, and small and scanty fibrinous concretions in six. According to Louis, 
the softening of the heart, and dissolved condition of the blood, bear a direct 
relation to each other, so that when the softening is very considerable, there 
is an entire absence of coagula. The researches of competent authorities 



INTERIOR VALLEY OF NORTH AMERICA. 493 

have also demonstrated a diminution of the quantity of fibrine in all cases not 
complicated with inflammatory affection, the diminution being in proportion 
to the severity of the disease. Air is also commonly found mixed with the 
blood in the extreme cases of dissolution. This, however, is not very 
uncommon in other diseases, especially where death takes place by as- 
phyxia. — Ed.] 



CHAPTER XIV. 

PATHOLOGY OF TYPHOUS FEVER. 

By a typhous fever, I mean one in which the onset is generally gradual, 
which is of a continued type, is prone to persist a long time, is not neces- 
sarily accompanied by any prominent local affection, in which the pulse is 
preternaturally frequent, but not preternaturally full or strong, in which the 
tongue becomes dry, and which in its progress is attended by subsultus 
tendinum, coma, and low delirium. * * * * 

I. It is not difficult by their symptoms, to throw the various forms of 
fever into natural groups, but to ascertain the peculiar pathological actions 
of each group, and establish in the mind the conception of different modes of 
morbid function, corresponding to the different symptoms, is a difficult, per- 
haps impossible task. For the solution of this problem, we can only refer 
to the phenomena during life, and the lesions found after death. The for- 
mer are signs, the latter effects of morbid functions. The actions them- 
selves are not matters of observation, but inference. We are compelled to 
believe in their existence, and equally required to believe in their diversity 
in the different groups of fevers, and also to a smaller extent, in the diffe- 
rent members of the same group. 

In attempting to assign the causes of these diversities, we are led in the 
first place to the external circumstances or agents on which fevers depend. 
I hold it to be a universal truth, that every agent which is capable of acting 
on the vital susceptibilities, produces an effect peculiar to itself. Many, it 
is true, are so analogous, as for example, the different kinds of food or alco- 
holic drink, that the effects, salutary or morbid, which they produce, may 
be readily confounded ; but others, as the occult influence which generates 
autumnal fever, the vicissitudes of atmospheric temperature and humidity 
which excite phlogistic fevers, and the animal poisons which occasion small- 
pox and measles, are specifically different in their modus agendi and effects. 
It is to etiology, then, that we must look for the primary and principal 
causes of variety in the type of fever. In the phlegmasiae, or phlogistic 
fevers, we have one type, in the periodical fevers another, in yellow fever 
another, in the eruptive fevers another, in the typhous another. Each of 



494 THE PRINCIPAL DISEASES OP THE 

these groups, except perhaps yellow fever, is susceptible of subdivision. 
This results in part from modification in the remote cause or causes common 
to the group, as in the periodical fevers, and from specific differences in the 
remote causes of the different members of the group, as in the eruptive 
fevers. But there are other, though subordinate causes of pathological dif- 
ference. The greatest of these is the local affection or inflammation, always 
present in the phlegmasise and a common occurrence in the other groups. 
When the seat of the inflammation varies, many of the symptoms vary like- 
wise, and thus we have an anatomical as well as analogical element of 
diversity. Finally, a third source of pathological modification is to be found 
in the previous condition of the system ; whether strictly physiological as 
connected with age, sex, temperament, idiosyncrasy, and acclimation, or 
g-imsi-pathological as connected with methods of living unfavorable to sound 
health, though not productive of manifest diseases. 

Fever, then, is a type of pathological action, assuming many modifica- 
tions, which may be thrown into groups, and then still farther subdivided. 
To compare these groups with each other, would be going into the general 
history of this form of disease, when our subject is but a single group, the 
typhous. It will be impossible, however, to study the characteristics of 
this group, without a frequent reference to those which are peculiar to 
others, or common to the whole. 

II. The symptoms and pathological lesions indicate a wide range of 
morbid action in the typhous fevers. The former have been observed in 
every function of the body, and the latter in every organ. Thus the signs 
and ravages of morbid action harmonize, and unite in demonstrating the 
universality of the pathological condition. 

In these fevers in fact both the solids and fluids are involved. The great 
primary function of innervation, animal and organic ; the coextensive and 
coequal sanguiferous function, including both the circulation and constitu- 
tion of the blood, are all changed from their normal condition, and as a 
necessary consequence, the dependent or subordinate functions of digestion, 
nutrition, secretion, excretion, calorification, sensation, and motion, are 
brought into a morbid state. 

Two views have been taken of the manner in which this morbid affection 
of the whole organism arises. According to one, the primary influence of 
the remote cause is concentrated upon a complete organism or tissue, where 
it raises an inflammation, which sympathetically affects the whole body, pro- 
ducing fever, and progressively involving other organs in inflammation. 
According to the other theory, a non-inflammatory morbid impression is 
first made on some susceptible surface, whence it is propagated through the 
nervous system until the innervation of the whole organism is involved. 
It signifies nothing to the validity of this hypothesis, whether the remote 
cause act upon the skin, a mucous membrane, or (being absorbed) upon the 
interior of the heart and blood-vessels. But there is a humoral modification 



INTERIOR VALLEY OF NORTH AMERICA. 495 

of the doctrine which must be stated. It may be that the remote cause 
exerts its effect on the blood, and altering the constitution of that fluid, its 
reactive influence on the solids becomes the immediate pathological cause 
of their morbid condition. The theory of a non-inflammatory morbid impres- 
sion does not exclude inflammation from the fevers we are considering, but 
makes it secondary, a consequence and not a cause of the fever. We must 
inquire into the comparative evidence in favor of a primary and a secondary 
inflammation. 

III. The inflammatory origin of typhous fever is suggested by two facts ; 
first, that inflammation can excite fever; second, that in those we are 
studying the symptoms and ravages of inflammation are generally seen. 
From these data their inflammatory origin has been deduced ; but the con- 
clusion is not warranted by the premises ; for it has not been shown that 
fever cannot arise without an antecedent inflammation, and we know that it 
can produce that local affection. The brain, or its envelopes, the mucous 
membrane of the stomach and duodenum, and the glands of the ileum have, 
by different pathologists, been designated as the seats of the primary inflam- 
mation. It is difficult to perceive why the lungs and spleen, especially the 
latter, should not have been added to the catalogue, as their lesions are 
nearly as constant as those of the other organs. When all of them are 
found affected in the same subject, how can the pathologist decide on the 
parent lesion ? He cannot do it by comparing them with each other ; for 
all seem to be of the same age; nor by a reference to the symptoms, for in 
numerous instances their appearance is contemporary, and even when those 
displayed by different organs are successive, it does not prove that the 
affection of one organ causes that of another, any more than the successive 
appearance of anasarca, ascites, and hydrothorax, in organic disease of the 
liver or heart, proves one of those dropsical effusions to be the cause of 
another. Moreover, each of the lesions which have been named is absent 
in different well-characterized cases of typhous, even in the same epidemic ; 
again, some of them, on which much stress has been laid, as, for example, 
the affection of the glands of Peyer, are much more limited than those found 
in other and more vital parts, which latter, however, are declared to be 
secondary or derivative ; still further, in many dissections of those who have 
died of these fevers, no inflammatory lesions whatever were found. Finally, 
to assign to these fevers a local inflammatory origin, is to blend them with 
the phlegmasiae, which is forbidden to some extent by their etiology, and 
to a greater degree by their symptoms, required treatment, and anatomical 
lesions. It may be admitted that some of these lesions are more frequent 
than others, as those of the brain in London, and of the Peyerian glands in 
Paris ; but this does not prove either of them aboriginal affections and the 
cause of the fever, unless it could be shown that inflammation never results 
from that constitutional affection, which I presume no pathologist would 
attempt. I recognize the frequent presence of inflammation in the typhous 



496 THE PRINCIPAL DISEASES OP THE 

fevers, also that a true phlegmasise sometimes puts on the garb of typhous, 
when the system has become exhausted, and that after the causes of that 
type of fever have impressed the system, some other cause, which in a 
healthy body would have excited a phlegrnasias, may develop an inflamma- 
tion with an associated typhous fever; but I cannot believe that inflamma- 
tion is necessary to the production of a typhous fever, or even favorable to 
it, but the reverse. 

IV. The advocates of primary inflammation in the typhous fevers do not 
differ as widely from the advocates of primary fever and secondary inflam- 
mation as at first view might be supposed. Take, for example, the brain, 
spleen, and ileac follicles, as the most frequent seats of lesion, how can the 
noxious agents reach those parts without first acting on many others ? And 
who will venture to declare that those others are insusceptible to the action 
of that agent ? Such an assertion would be entirely gratuitous, and thus 
we are, I think, driven to the conclusion, that other parts of the organism 
must be morbidly impressed before those which have been named, which 
is, in fact, all that the theory of a constitutional origin of the inflammations 
in the fevers now under consideration requires. 

Much stress has been laid on the well-known fact that inflammation from 
causes entirely topical in their application, does occasion fever; but this 
argument in favor of the inflammatory origin of all fevers, loses its conclu- 
siveness when opposed by the well-ascertained fact, that inflammations arise 
in the progress of fevers. These are said, however, to be sympathies with 
the organ first inflamed, but this is an assumption in every case in which 
we do not have proofs of an inflammation antecedent to the fever. More- 
over, there are facts which prove that fevers do originate inflammation. 
Thus an autumnal intermittent which within the few first days can be cured 
by liberal doses of opium and sulphate of quinine, may if neglected, present 
well-marked splenitis, which will render those medicines ineffective till after 
a free bleeding, and in small-pox everything indicates that the fever pre- 
cedes all local inflammation. Facts in support of this theory, may even be 
drawn from the phlegmasia^ themselves. Thus every physician has met 
with cases of rheumatism and pneumonia, in which the fever preceded the 
inflammation, the local affection seeming to be the offspring of the consti- 
tutional. Commonly, however, they arise at the same time, and it is pro- 
bable that in many cases of typhous an inflammation arises simultaneously 
with the hot stage. During the depression, the capillary circulation of some 
organ has become stagnant, and the vessels over-distended, in consequence 
of which, when general febrile reaction occurs, local inflammatory reaction 
arises; such an inflammation, however, is not the cause, but a part of the 
fever. It may be that visceral passive hyperemia may continue for a while 
after the fever has been established, and then change to active hyperasmia or 
inflammation. 

V. From the facts and arguments which have been stated, I am satisfied 



INTERIOR VALLEY OF NORTH AMERICA. 497 

that although an inflammation may precede a typhous fever, it is not a 
necessary or common antecedent, and that the inflammations (so called) 
which are so often present result from the fever itself; and here an important 
question arises, — are there some typhous fevers which constantly produce 
one inflammation, and others which as constantly produce another? for if such 
be the fact, they are specifically different, and the search after a distinct 
anatomical character for each should still be prosecuted. This will pro- 
babty long remain an open question. Up to the present time, all attempts 
so to connect causes, symptoms, and anatomical lesions, as to construct dis- 
tinct and permanent species, have in my own opinion been unsuccessful. 
I believe that one febrile diathesis is common to the whole, while the local 
affections vary according to no fixed law. 

A typhous diathesis with the capability of generating inflammation (so 
called) being granted, we are prepared to expect a diversified exhibition of local 
lesions, none of which would be always necessarily present. We may draw 
an instructive lesson on this point from that form of constitutional irritation 
which is called hysteria. It may not only arise from a great variety of causes, 
as I suppose the typhous diathesis to arise, but what is more to our present 
purpose, it falls with energy on various organs, even in the same paroxysm of 
the same patient. But more especially in different individuals, it may show 
itself as diabetes, colic, vomiting, dyspnoea, palpitation of the heart, hemi- 
plegia, and even insanity j yet no one would undertake to construct different 
species out of these local irritations. Again, our autumnal fevers, which make 
but a single species, characterized by what I may hypothetically call a malarial 
diathesis, generate various anatomical lesions, none of which are always pre- 
sent ; and the same fevers leave behind them a neuralgic diathesis, out of 
which arise in different cases, neuralgias of nearly all the organs of the 
body, yet no physician would attempt to erect them into a separate species, 
but distinguish the whole from the fixed and persistent tic douloureux, which 
he would regard as specifically distinct. 

From various analogies we may conclude, that there are predisposing or 
exciting auxiliary causes, which modify the local ravages of the typhous 
diathesis, some of which may even extend to whole communities or races, or 
prevail through particular epochs, and yet constitute no solid foundation for 
distinct species. Goitre is accompanied with cretinism in the mountains of 
Europe, but not in our Interior Valley. In the tropical regions, remittent 
fever produces severe disease of the liver, in our higher latitudes much 
oftener of the spleen. Sudden changes of temperature generating a phlo- 
gistic diathesis, produce tonsillitis in one, pleurisy in another, and arthritic 
rheumatism in a third, according to their respective predispositions. When 
there is a hereditary tubercular diathesis, infancy may determine the deposit 
of tubercle upon the mesenteric ganglia, childhood upon the brain, youth upon 
the cervical ganglia, and adult age upon the lungs. With such facts before 
us, may we not conclude that national physiologies and modes of life may 

vol. ii. 32 



498 THE PRINCIPAL DISEASES OP THE 

signally diversify the local lesions in a typhous diathesis ? And may we not 
thus understand how, in different countries and among individuals in the 
same country, there may be a great variety, and yet the constitutional 
affection be everywhere specifically the same? 

The symptoms are necessarily modified by the local affections, while the 
aspect of the constitutional diathesis remains unchanged. They cannot of 
course be the same when the brain suffers most, as when the lungs or the 
glands of the ileum and mesentery are the chief seats of lesion ; yet the 
character of the fever may still be accurately expressed by the same word. 
This change once took place in an epidemic of this country, which began 
as a petechial or spotted fever, and ended as a typhoid pneumonia. Every 
physician observed the difference in certain symptoms, yet no one failed to 
recognize the same typhous diathesis in both, constituting them essentially 
the same fever. To the study of this diathesis we must now apply our- 
selves. 

VI. Lesion op Innervation. — The history of the typhous fevers in- 
dicates an early, if not a primary, morbid state of the innervation ; which 
all the phenomena declare to be one of adynamia with irritation : a failure 
in the vis nervosa, with perversion; a degradation, with abnormal molecu- 
lar actions. When the nervous system, to employ an expression metaphori- 
cally, is thus crippled, we may expect to see the functions to the perfor- 
mance of which it contributes — which it sustains, co-ordinates, and har- 
monizes — enfeebled and disordered; and such is their condition in the 
fevers we are now considering. The whole of them present the same type 
of morbid innervation ; but in the beginning of some, as in the cases which 
have received the name of synochus, the nervous impairment and irregu- 
larity are moderate in degree ; yet, should the disease not be arrested, they 
come at length to display all the characteristic phenomena of the class. 

The typhous lesion of innervation is not like certain forms of constitu- 
tional irritation, produced by mechanical injuries or burns, or following 
hemorrhages, or hysterical agitations from uterine irritation or mental emo- 
tion, most of which are of transient duration ; but on the contrary, it is 
prone to continue, and in many cases displays an ingravescence which no 
treatment can arrest. It is not always primary. For example, it often 
arises in the progress of a remittent autumnal fever, and sometimes in the 
latter stages of one of the acute phlegmasiae ; especially inflammation of 
the brain. It occurs also in some cases of erysipelas ; in certain invasions 
of the eruptive fevers; and, occasionally, in epidemic dysentery. Thus 
while it may appear in the beginning of a fever (and constantly does in 
those which are properly called typhous) as the proximate or first effect of 
a remote cause or causes, it may arise secondarily, as a result of a partial 
exhaustion of the vital forces, or of a morbid condition of the blood. 

Of course, there can be no general lesion of innervation without involve- 
ment of the nervous centres, both animal and organic. When the former, 



INTERIOR VALLEY OF NORTH AMERICA. 499 

especially the brain, is deeply implicated, it is common to regard that organ 
or its membranes as in a state of inflammation, and to ascribe the symptoms 
to that condition; but in many cases they are mitigated or removed by a 
treatment, which could not fail to aggravate inflammation; and quite as 
often when they have continued to the end of life, a post-mortem inspection 
has failed to discover the ravages of that local affection. When the brain 
is brought into this inscrutable state of irritation, all the functions over 
which it presides are necessarily impaired; and hence the disordered state 
of the mind and special senses ; the debility and irregularity of action of 
the muscles of animal life; the feeble contraction of the heart; the failure 
in the capillary circulation with a tendency to non-inflammatory congestions ; 
in part at least, the failure in nutrition ; and the production of a vitiated 
character of the secretions. In other cases, the irritation may especially 
affect the spinal cord, and in others still, we may suppose the ganglionic 
system to suffer most, thus giving a variety in the symptoms which cannot 
be successfully analyzed, till we acquire a more perfect knowledge of the 
relative influence of the different nervous centres on the functions of organic 
life. 

Of all the functions dependent on, or subordinate to the nervous, that of 
muscular motion both animal and organic is the most extensive. If the 
contractility of muscular fibre be not derived from the nervous system, the 
integrity of that system is a condition manifestly necessary to the normal 
performance of muscular motion, both voluntary and involuntary. In most 
cases of typhus, an early impairment of muscular function is conspicuous, 
and long before the termination of the fever, it becomes greater than in 
any other disease except paralysis. The patient can neither protrude his 
tongue nor maintain a posture in opposition to the force of gravitation ; his 
power over the sphincter ani is lost, and he can no longer throw the bladder 
and the muscles concerned in urinary excretion into action. It is worthy 
of remark that involuntary discharges from the bowels often coexist with 
retention of urine. This may possibly indicate that the intestinal secre- 
tions are more abnormal and irritating than the urinary; but other causes 
are less equivocal. First, many of the medicines administered act directly 
on the intestinal mucous membrane, few or none likely to be given on that 
of the bladder ; second, the food which is taken may remain undigested 
and become by the results of its spontaneous decomposition an irritant to 
the bowels; third the follicular or mucous inflammation or ulceration so 
often present in the latter, may combine with the other irritants in excit- 
ing a contraction of the muscular tunic of the bowels, which might other- 
wise remain as torpid as that of the bladder. Thus involuntary alvine dis- 
charges, of which the patient is often conscious, indicate not only loss of 
power over the sphincter, but great irritation in the bowels above ; and are 
therefore always more portentous than retention of urine, or inability to 
project the tongue. 



500 THE PRINCIPAL DISEASES OF THE 

Subsultus tendinum appears to depend on involuntary, feeble, irregular 
radiations of nervous influence from the brain or spinal cord, into certain 
muscles of animal life. I am not aware that those of organic life are ever 
affected in that manner. Why the muscles of the arms and hands are 
chiefly affected, I cannot say, unless it result from the incessant influence 
of the will over these extremities in health. In secondary typhous, occur- 
ring suddenly, after a late bleeding, in autumnal remittent fever, I have 
seen the greatest number of muscles affected with spasmodic twitching. 
The circumstances under which this muscular affection arises, not less than 
the influence of treatment, demonstrate that it does not depend on a state of 
super, but of sub-nervous excitement. Carphology, or pickings and grasp- 
ings at unreal objects, are voluntary movements, resulting from motives. 
They sometimes extend to the whole muscular apparatus of animal life, as 
when the patient attempts to leave his bed and seek some other situation. 
Subsultus tendinum often exists without these morbid volitions, but they 
are invariably preceded or attended by it. They indicate, therefore, a more 
serious lesion of innervation. They may and undoubtedly do occur, in 
connection with cerebral inflammation; yet such cases, lam convinced, con- 
stitute exceptions, for I have seen them promptly and permanently subdued 
by the administration of narcotics. 

The various forms of disordered muscular motion which have been de- 
scribed, may result from mere functional lesion of the nervous system ; but 
occasionally we see extremital paralysis, squinting, and dilated pupil. 
These muscular affections indicate cerebral pressure from serous effusion, 
and are more ominous than the feeble morbid contractions produced by 
mere nervous irritation. 

Morbid sensation and intellection, are other effects of the lesion of inner- 
vation in these fevers ; the former prompts to carphology, the latter occa- 
sionally shows itself in the form of active delirium, suggesting (in some 
cases correctly), actual inflammation of the brain ; yet in others, an anti- 
phlogistic treatment gives no relief, while narcotics and stimulants produce 
beneficial effects, and therefore indicate mere irritation of the cerebral mass. 
The results of their administration are familiar to those which they afford 
in mania a potu. A medical judgment matured at the bedside of the sick 
is necessary to an accurate discrimination among these cases. The more 
common and characteristic muttering delirium, from which the patient may 
be temporarily redeemed by pointed interrogatories, is of a less doubtful 
character, and never I suppose indicates inflammatory orgasm of the brain. 
The reactive influence of the irritated organs, maintains simply an excited 
state of the imagination. 

This outline of the principal effects of morbid innervation in the organs 
of intellection, sensation and motion is a mere statement of phenomena, 
not an explanation of their mode of production. This I suppose will be 
impracticable, until microscopic anatomy, and experimental physiology shall 



INTERIOR VALLEY OF NORTH AMERICA. 501 

have more fully revealed the secrets of the nervous system. Till then we 
must employ the terms which merely express departure from the abnormal 
condition of the nervous system. Our own feelings and observations on the 
functions of our own bodies, and those of others of similar organization, 
give us a standard of normal function, with which we may compare all de- 
partures, while we may still remain ignorant of the efficient cause of any. 
"We may admit, or even recognize varieties of departure from the physiolo- 
gical state, and experimentally assign to each its appropriate remedy, while 
we remain ignorant of the intrinsic nature of the vital forces and the mole- 
cular movements of the organism even in health. The terms asthenia, 
adynamia, debility, depression, enervation, exhaustion, simply suggest re- 
duction in the vital powers resident in a tissue ; the terms alteration, change, 
perversion, morbid action, irritation, merely express a departure in mode 
from the physiological or normal working of those powers. The two are 
combined in the typhous fevers. The term irritation, borrowed from the 
mind and figuratively used, to express a morbid condition of the body, has 
been decried because of its vagueness; and many attempts have been made 
to define its meaning, restrict its application, and fix its place in the science 
of pathology; but the time for making it a technical term of definite mean- 
ing has not yet arrived. Meanwhile the profession will continue to employ 
it as a comprehensive and convenient expression for many forms of disor- 
dered innervation, both local and general, for which perhaps no terms more 
definite will ever be used. Some irritations accumulate blood in a part, and 
are thus the proximate or immediate causes of inflammation — others do not. 
They differ in their effects on the capillary circulation. The congestion ad- 
dresses itself to the eye, and diverts attention from the lesion of innerva- 
tion which preceded and produced it ; and which is as inscrutable as that 
which does not generate a hyperaemia, or even occasions anaemia. The 
pathological state of the innervation, which we have reviewed, is doubtless 
an element in the lesions of nutrition, secretion, and calorification, which are 
present in the typhous fevers ; but we cannot follow it into these until we 
have inquired into the state of the circulation and the constitution of the 
blood in those maladies. 

VII. Lesion of the Circulation. — Daily observation on what takes 
place in our own systems, and in those around us, while they are in health, 
affords abundant evidence of this influence of the nervous over the sangui- 
ferous function ; and as pathological is but abnormal physiological action, it 
follows of necessity that when the innervation has become morbid, the cir- 
culation cannot remain healthy. The typhous lesion of the circulation har- 
monizes with that of the innervation. In the beginning of many cases of 
fever the energy of the heart is but little impaired, is, indeed, sometimes 
increased ; but this condition is transient ; and the real condition of that 
organ is one of adynamia or enfeeblement, connected with that state of its 
contractility, which leads to great frequency of contraction. In the peri- 



502 THE PRINCIPAL DISEASES OF THE 

odical fevers of autumn, the frequency of contraction is paroxysmal, in the 
typhous, persistent, though not without a slight morning abatement. In 
cases of great malignity, the adynamia of the organ is extreme, constituting 
indeed one of the most dangerous elements of that pathological state. In 
this condition it wavers, and its contractions become unequal and irregular 
in their succession, a phenomenon which it commonly exhibits in advanced 
stages of milder cases. 

But, as in other forms of fever, the central organ of the circulation is not 
the only portion affected. The arterial system participates in the lesion ; and 
although it may be difficult to distinguish the irregularities of action which 
depend on the heart, from those resulting from the morbid condition of the 
vital properties and cohesion of the arteries themselves, the physician who has 
been accustomed to compare the state of the pulse in these fevers with that in 
certain non-febrile but morbid states of the circulation, feels that there is a 
difference. The arteries, however, which are merely conducting tubes, and 
have but a limited nervous endowment, participate less in the morbid con- 
dition, than the two extremities or poles of the sanguiferous system, — the 
heart and the capillary vessels. 

The capillaries make up a large proportion of most of the vital organs ; 
they are liberally endowed with nerves, derived, in the viscera, chiefly from 
the ganglionic system in other parts, mainly from the cerebro-spinal ; they 
are the seats and instruments of active molecular function, and the quantity 
of blood which those of any organs contain, or transmit in a given time, 
while in a healthy condition, is various. Holding this position in the 
organism and functions of the body, they must of necessity be involved in 
the first failure or degradation of the nervous function, and hence the origin 
in part of those congestions and pseudo-inflammatory hyperemias so cha- 
racteristic of the typhous fevers. These occur in various organs and tissues ; 
may exist for a time in one, then cease and form in another; or may co-exist 
in several. By oppressing or otherwise deranging the functions of the part 
in which they occur, they modify the symptoms, and add a new element of 
danger. Inseparable from the typhous diathesis, they are found in all the 
forms under which it appears; and have been seized upon by some nosolo- 
gists for the purpose of constructing species, while others with juster views 
of their origin have regarded them as a merely suggesting varieties. 

The feebleness and irregularity of action in the heart and arterial sys- 
tem, seem to be connected with a molecular anatomical change. The for- 
mer organ is often found softened. As there is no absolute standard of 
firmness, a small degree of softening may readily escape observation ; and 
we are at liberty to infer its existence as a more frequent occurrence than 
the reported cases would strictly authorize. This softening is not, I pre- 
sume, confined to the heart; but in all probability extends to the arteries, 
and explains in part the undefinable peculiarity of pulse, to which I have 
referred. The arterial tissue, however, from having less of true vital pro- 



INTERIOR VALLEY OF NORTH AMERICA. 503 

perty, and more of that which is purely physical, may not undergo soften- 
ing as easily as the heart. The decrease of cohesion, doubtless extends to 
the capillary system, and may be one of the causes of the passive conges- 
tions which have been described, and of the punctate extravasations, called 
petechial, and of the other hemorrhages, so characteristic of these fevers. 
In proportion as the parietes of the capillaries lose their density of tex- 
ture, their containing power is of course diminished. 

VIII. Lesion of the Blood. — Facts and observations which are gene- 
rally admitted, demonstrate a lesion of the blood in the typhous fevers; 
but in what stage it begins, or in what it consists, are questions which can- 
not be fully answered. That it sometimes precedes any lesion of the solids 
seems probable from the following facts. 

1. The continued use of innutritious, or unhealthy diet, is well known to 
be a cause of typhus. Now it seems more reasonable to suppose that such 
a diet modifies and degrades the constitution of the blood, than that it leaves 
that fluid unchanged, and exerts a noxious influence on the solids. A 
scorbutic lesion of the blood is well known to arise from unhealthy food, 
and between it and the typhous lesion, there are many resemblances. The 
latter moreover has been known to coalesce, as it were, with the former; 
thus generating a more fatal disease than either uncombined. 

2. In our ships and penitentiaries, lodgings which are small, close, foul, 
and humid, often generate a scorbutic diathesis, and under such circum- 
stances we also see a typhous diathesis produced, which we may presume to be 
primary, inasmuch as the excretions from the skin and mucous membrane 
of the lungs are retarded, while peccant matters doubtless find their way 
into the blood through the latter tissue. The exhalation of a violet odor 
by the urine after inhaling the vapor of turpentine : the production of a 
mercurial disease by sojourning in an apartment where quicksilver is slowly 
volatilized ; and the offensive character of the perspiration in those who 
spend most of their time in the dissecting room, as happened with Bichat, 
are demonstrative of a pulmonary endosmosis, by which the blood may be 
primarily affected. It is well known moreover that a transient visit to the 
bedside of a typhous patient, is harmless, while to spend a night in his 
apartment, with the doors and windows closed, is often followed by an 
attack of the same fever. 

TTe may conclude then that in some cases of typhus, the initiatory 
lesion is in the blood. But when a foreign agent is thus introduced, its 
effects are not limited : to that fluid, for it acts directly upon the heart 
and vessels, the vital forces of which it degrades and disturbs, whereupon 
the general innervation is lowered and perverted in the manner that has 
been already pointed out. But the influence of an altered constitution of 
tjie blood on the vascular and nervous systems, on the whole economy 
indeed, must not be overlooked. Of the reciprocal, though inscrutable 
action of the solids and fluids in health, we are, as I have already remarked 



504 THE PRINCIPAL DISEASES OF THE 

well assured ; and we may safely conclude, that if either be changed from 
a normal state, the other must quickly become morbid. A deteriorated 
blood cannot therefore circulate through the organs, without immediately 
reducing and perverting their functions. We have not, however, mere 
a -priori or argumentative proof of sanguineous degradation. All our 
original writers describe the drawn blood in the more malignant forms of 
typhous fever, as signally changed from a natural condition. They have 
called it dissolved, even putrid. We, ourselves, have witnessed in some 
cases its imperfect, even insular coagulation, and the general absence of 
the buffy coat which characterizes the phlogistic fevers. But the blood of 
typhous patients has been submitted to a more rigorous examination. An- 
dral and Gavarret have ascertained that there is very often a diminution of 
the fibrine j and never an increase, except upon the accidental rise of an 
inflammation. This decrease, however, is not a necessary condition to the 
existence of these fevers, for in their early stages and throughout the whole 
course of the milder cases, the fibrine keeps up to its ordinary proportion of 
three parts in a thousand. When, however, they assume a protracted form, 
or a malignant type, a decrease in the amount of fibrine is unfailing. On 
the other hand the red corpuscles are often increased, though sometimes 
diminished. 

Not having an opportunity of consulting the original publications of 
Andral and Gavaret,* I have collected from Simonj the data (furnished 
by them) for an estimate of the proportion of these two elements, in six 
cases of the typhoid fever of Paris. Twenty bleedings were employed, and 
the average fibrine was 2-45, red corpuscles, 160-7; the healthy number of 
the former being 3-0, of the latter, 127-0. The lowest cipher for the fibrine 
was 0-9, the highest, 3-7; the lowest for the corpuscles, 64-0, the highest, 
3*10, the extremes being found associated in the same blood. 

Becquerel and RodierJ examined the blood of eleven typhoid patients. 
On the first bleeding, the average of the fibrine was 2-8, of the corpuscles, 
127*4. Four of the patients were bled a second time, when the averages 
were, fibrine 2-3, corpuscles, 1245. If we take the whole of the bleedings, 
numbering thirty-five, by these various experiments, and reduce them to 
mean terms, we have fibrine 2 5, corpuscles 146. The normal number for 
the former being 3, for the latter, 127. Thus, the fibrine had diminished 
16-66 per cent., while the corpuscles had increased 14-97 per cent. 

The reduction of fibrine in this fever, when severe or protracted, is un- 
questionable, but Andral inclines to the conclusion, that the excess of cor- 
puscles should be referred to the physiological condition of those who are 
most liable to typhoid fever. But the augmentation seems to me so con. 
siderable and uniform as to demand an opposite conclusion. It is chiefly 
in the early stages, however, that this excess is decidedly manifest ; in 
latter periods, the corpuscles not less than the fibrine are often diminished. 

* Annales de Chimie et Physique. f Chemistry of Man. $ Chem. of Man. 



INTERIOR VALLEY OF NORTH AMERICA. 505 

To the diminution of fibrine in typhous fevers, that distinguished patho- 
logist, with great plausibility, ascribes several of their characteristics. 

1. The imperfect coagulation and loose texture of the clot, together with 
the general absence of a buffy coat. 

2. The adynamia, at least in part. 

3. The congestions so apt to form in these fevers, giving to the organs, 
as seen after death, a state of hyperemia, without the products of inflam- 
mation. 

4. The hemorrhages, in the form of petechiae, or from the mucous mem- 
branes. 

In the twenty bleedings by Andral and G-avarret, already mentioned, the 
average of solid residue from the serum was 864, that of healthy blood 
being 80. The same bleedings, together with fifteen by Becquerel and 
Rodier, gave for the water of the blood an average of 800, that of healthy 
blood being 790. These numbers indicate that the serous elements of 
the blood are so little augmented in typhoid fever, that we may regard the 
diminution of fibrine and increase of corpuscles (neither, however, invariable), 
as pathological characteristics of the blood in that fever. Of the compara- 
tive state of the blood in those forms of typhus which affect the brain rather 
than the abdominal viscera, we know too little to permit a general conclusion. 

It is, I think, impossible not to believe that other changes than those 
which are found in the relative proportion of the proximate elements of the 
blood, must occur in the typhous fevers, changes which animal chemistry 
may never be able to define. Composed of the elements of all the solid 
tissues, and all the secretions; continually receiving new matters from 
without to be associated to itself, and old ones detached from the tissues to 
be ejected from the system, a more complex and diversified play of affinities 
goes forward in that fluid, than exists elsewhere in the organic or inorganic 
world. It is the office of the power which presides over and controls these 
affinities, to preserve them in a condition of unvarying equipoise ; but to 
this power are opposed all the causes of disease ; and whenever one of them 
prevails, — whenever a single composition or decomposition is interfered 
with, the whole concurring to one end, are or may be disturbed, although 
our means of examination may not enable us to perceive or estimate the 
character or extent of the lesion. Thus, if a fixed star should be annihilated 
or displaced from its position, a disturbing influence would spread through- 
out the physical heavens, which although not perceptible to a common 
observer, would be demonstrated as a necessary reality by the astronomer. 

That lesions of the blood play an important part in the production of 
morbid states and phenomena in the typhous fevers, cannot, I think, be 
doubted. 

1. They react upon the nervous system, and augment or maintain its 
irritation and depression, which conditions, in turn, increase the sanguineous 
degradation. 



506 THE PRINCIPAL DISEASES OF THE 

2. They act on the contractility of the muscular system, and contribute 
to the enfeeblement of that portion of the body. To the heart they are 
depressing irritants, maintaining it in perpetual morbid contraction, and 
thus preventing intermissions in the fever. 

3. They explain in part the suspended state of nutrition, and the dimi- 
nution of cohesion or softening so constantly present in all the tissues. 

4. They probably occasion those hyperemias so characteristic of the 
typhous fevers ; most of which are passive, others active or inflammatory, 
according to the degree in which the fibrinous element of the blood is 
reduced or unreduced in quantity, or deteriorated in quality. For we may 
safely believe that unhealthy blood may not be able to make its way through 
the capillary vessels as readily as the healthy blood, which is their appro- 
priate and genial stimulus. 

To the diminution of fibrine, or the absence of any increase, we may, as 
already intimated, ascribe the infrequency of true inflammation in the 
typhous fevers. Careless or unskilful anatomists often confound simple 
with inflammatory congestion. This mistake has greatly misled the profes- 
sion. But a small proportion of the congestions found in our post-mortem 
inspections in the typhous fevers, have been accompanied by those actions 
which constitute real inflammation. Serous effusion is common, fibrinous 
comparatively rare; and even when coagulating lymph is effused, it is not 
always plastic and highly organizable, as in the phlegmasise, indicating that 
the protein elements of the blood are not in a normal condition. 

5. The non-inflammatory congestions may be, in part, the causes of the 
hemorrhages so frequent in these fevers, a diminution of vital cohesion in 
the vessels themselves, and a state of hyperinosis or diminished fibrine, con- 
tributing liberally to the same effect. In the early stages of the fever, the 
congestion is perhaps the chief cause of the hemorrhage, which is then often 
followed by mitigation of the symptoms, and, therefore, regarded as a 
favorable sign, — in the advanced stages, when it is generally more copious, the 
other pathological conditions are present, and the prognosis is therefore bad. 

6. In the present state of our knowledge concerning the physiology of 
the spleen, it is not possible to connect the swelling and softening of that 
organ with the lesions of innervation, circulation, or blood, yet that they 
result from the two latter, cannot reasonably be questioned. 

7. In the same category with the hemorrhages and splenic lesions, we 
may place the cutaneous, punctate hypersemias, and extravasations, known 
under the name of rose-colored spots, petechias, and vibices. The earlier 
they occur in the fever the brighter is their red, and the more completely 
can they be made to disappear under pressure, no extravasation having yet 
taken place. In the more advanced stages, when the blood has arrived at 
a deeper deterioration and the parietes of the vessels have lost their firm- 
ness of texture, extravasation replaces congestion ; the color of the spots is 
darker ; and the prognosis from them is of course more unfavorable. 



INTERIOR VALLEY OP NORTH AMERICA. 507 

Of the rash or pimply efflorescence, which frequently occurs in the 
typhous fevers, it is more difficult to speak in connection with the patholo- 
gical condition of the blood. Of course every pimple however small con- 
sists essentially of a congeries of capillaries injected with blood — is a limi- 
ted hyperemia. We may presume, that the tactile papillae, each of which 
is supplied with an artery, are the seats of this congestion and consequent 
enlargement. It may be, however, that the sebaceous and sweat-glands 
are also the seats of congestion, giving a pathological condition analogous 
to that of the solitary and aggregated glands of the ileum, of which so 
much has been written in the works on these fevers. 

In seekiDg further for a pathological cause of the cutaneous affections 
in the typhous fevers, we may speculatively refer to the hypothesis of Lie- 
big, that in the true eruptive fevers, a change is effected in the blood by 
the introduction of a specific ferment, to which change the cutaneous exan- 
thems are to be attributed. Were this established, we might analogically 
infer that the exanthems in certain typhous fevers have the same patholo- 
gical cause. 

8. The lesion of the solitary and aggregated glands of the ileum, occur- 
ring in one form of typhous fever, appears to consist in a congestion, and 
the deposit in them of a peculiar substance, which has been called the 
typhous material. The resemblance of this lesion, to that of the same 
parts in phthisis, will be at once perceived. Now it cannot be doubted that 
the elements of tubercle are developed in the blood, and thence secreted into 
the pulmonary and various glandular tissues. We call such a condition 
the tubercular diathesis ; and may we not with equal propriety speak of a 
typhous diathesis ? It seems to my own mind at least highly probable, 
that the glandular lesions of the bowels are referable to a morbid condition 
of the blood. 

9. It is well known, moreover, that the parotid and other glands are 
liable to suppuration in the fevers we are now studying. Cellular abscesses 
are also more common than in other forms of fever, and with the whole we 
might perhaps connect the bed-sores, which so often prove intractable. 
Shall we refer all these affections to lesions of the solids only ? I see no 
reason for such a restriction. On the contrary, while I would grant the 
reality of lesions of innervation and circulation, I am disposed to believe, 
that a lesion of the blood is an important agent in their production. 

10. There is no form of fever in which the secretions generally become 
so morbid and offensive as in the typhous. The exhalations from the lungs 
and skin are offensive ; the sordes or inspissated secretions of the mouth, 
which accumulate on the teeth and gums present a repulsive — and of these 
fevers, highly characteristic — aspect; the urine emits an offensive odor, a 
healthy bile is scarcely ever secreted, and the alvine discharges, exceedingly 
diversified in appearance, are in many cases intolerably fetid. That this 
extraordinary lesion of the whole secernent function arises in part from the 



508 THE PRINCIPAL DISEASES OF THE 

lesion of innervation, cannot be denied ; but the deterioration of the blood 
is a more influential proximate cause. It may be unhesitatingly affirmed 
from all we know of the state of the secretions in various forms of non- 
febrile constitutional irritation, and in the phlogistic fevers, generally, 
that while supplied with healthy blood, no alteration in the condition of the 
glands and secreting surfaces can cause them to excrete such heterologous 
fluids, and we may as fearlessly affirm, that if the glandular apparatus were 
perfectly normal, it could not elaborate normal secretions from the deterio- 
rated aDd degraded blood of typhus. 

Our predecessors, in expressing this condition of that fluid by the term 
putrid, were not so far amiss as the bigoted solidists have pronounced 
them. The glands but combine elements furnished them by the blood, and 
if what they pour out have a stench which suggests putrefaction, a decom- 
position, at least bordering on that expressed by the term which they em- 
ployed, seems to be indicated. It has been found, moreover, that the bodies 
of those who die early, and through the disease have exhibited a decided 
vitiation of the blood and secretions, putrefy long before the ordinary time, 
disclosing, as it were, that the process of decomposition had already com- 
menced during life. 



CHAPTER XV. 

TREATMENT OF TYPHOUS FEVER. 



SECTION I. 



I. All the physicians who have met with typhous fevers, in any part of 
the Interior Valley, have had reason to complain of the results of treatment. 
Accustomed to resort to an active antiphlogistic method in the phlegmasia, 
they are generally successful ; and understanding the invaluable antidotal 
properties of sulphate of quinine in our autumnal fevers, they administer it 
liberally, and in most cases arrest the fever if called in the early stages. 
Not so with the typhous fevers. At first view it might be supposed, that 
from their limited prevalence, the physicians of the Valley have not had ade- 
quate opportunities for studying them therapeutically, and there is perhaps 
some reality in the supposition j yet we must not forget their identity or 
very close resemblance to the typhous fevers of Europe, the book-study of 
which is not neglected, in a country which looks with filial dependence to 
the writings of its British ancestry. From Cullen down to Watson, nearly 



INTERIOR VALLEY OF NORTH AMERICA.' 509 

all the systematic works of England, Scotland, and Ireland, have been illus- 
trated and adapted to the climate and state of society of the United States 
by zealous and painstaking annotators, who have thus made them the 
standard authorities of the practitioners of the Interior Valley. Several 
French and G-erman works, moreover, have from time to time been transla- 
ted, and received with favor by us. It cannot then be said, that our disap- 
pointments have resulted from a neglect of European instruction; but 
should be referred to its inadequacy. I presume, however, that the prac- 
tice recommended by our foreign teachers has been as successful here as 
elsewhere. The difficulty lies more in the nature of those fevers, than in 
the imperfect therapeutic science of Europe, or of its unfaithful application 
in America. 

II. By different physicians of the Valley almost every part of the treat- 
ment advised in the Old World, has been pushed to its utmost limits. This 
is true of bloodletting, purging, calomel, tartar emetic, sulphate of quinine, 
stimulants, and blisters, each of which, made, by turns as it were, the prin- 
cipal, and others the auxiliary remedies, has been employed with our charac- 
teristic energy, till it was found to fail, and then abandoned. The whole, 
moreover, according to the varying states of the system have been employed 
in the same case, but so often with the same want of success, that many 
physicians have, in opinion if not in practice, come to regard all treatment 
as useless if not injurious. Not, however, to dwell on extreme views, I 
may say, that the most judicious physicians of the Valley have been brought 
by experience to the conclusion, that no method will cut short our typhous 
fevers, and that although much may be done to restrain their ravages, and 
secure a favorable termination, all decidedly debilitating or perturbating 
treatment is injurious and should be avoided ; a conclusion which is sup- 
ported by my own observation. 

III. It may be profitable to devote a few paragraphs to the question, 
why the typhous fevers, as a general fact, cannot be arrested by treat- 
ment. 

1. Those which arise from contagion may be thrown into the category 
of other contagious diseases, most of which are intractable. The eruptive 
fevers and hydrophobia have not yet been stopped in their course ; but 
syphilis has. The fact that the typhous fevers have not a uniform duration 
like the eruptive, the uniformity of which, however, has been overrated, 
does not exclude them from this classification, for hydrophobia and syphilis 
have no definite times of continuance, although the latter has a succession 
of stages like small-pox. To refer the typhous fevers to this class, is not 
however an explanation of their obstinacy ; but merely placing them in a 
position to be studied with those which have so long presented the same 
trait of character, that we have ceased to wonder at the failure of all our 
efforts to arrest them. 

2. But there are cases of typhous which do not originate from conta- 



510 THE PRINCIPAL DISEASES OF THE 

gion; and what shall be said of them ? If we say of the others, that they 
depend on a specific poison, which establishes in the system a peculiar 
morbid action, not amenable to any known remedy, we cannot say it of 
cases which arise independently of such a cause. Yet we may believe that 
it may be a law of innervation, that when it is perverted in the manner and 
to the degree which are necessary to the production of a typhous fever, 
its restoration to a normal condition may be little promoted by any medi- 
cinal agency. We may even say that the failure of our therapeutic efforts is 
an instructive index, or a good measure of the departure from a normal 
condition. The obvious perturbations of the nervous system, do not always 
enable us to estimate the obstinacy and danger of the lesion of innervation. 
These are disclosed to us by the results of medication. Thus a neuralgia 
of the first branch of the fifth pair of nerves is curable with sulphate 
of quinine, while the same degree and kind of pain in the second branch 
is not relieved by that medicine ; and the agitations of the nervous system 
in hysteria are quite as manifest as in hydrophobia, while the former are 
removed by assafcetida, and the latter continue till death under any kind 
of treatment. Whether we shall ever find a medicine whose impress will 
supersede the typhous irritation of the nervous system, as assafcetida sub- 
dues the hysterical, cannot before seen. Should such a remedy be found, 
the typhous fevers would be transferred from the incurable to the curable 
catalogue of maladies. 

3. But the question before us is not fully answered, even granting the 
reality of these speculations. In searching for the causes of obstinate per- 
severance in these fevers, we must not overlook the lesion of the blood. 
The chlorotic lesion is removed by chalybeates, the scorbutic by the vege- 
table acids, but as yet we have discovered no remedy for the typhous lesion. 
In both those diseases there are serious lesions of function in the solids, 
yet they at once yield to the correction of the morbid states of the blood. 
Till the means of making those corrections were discovered, those diseases 
were intractable. Agents which acted primarily on the vital properties of 
the solids, did not reach them. May we not assume then that the lesion of 
the blood in typhus, is a cause of the endurance of that fever, and are we 
not authorized to hope that sooner or later, experience, which in many 
things goes ahead of philosophy, the a posteriori taking precedence of the 
a priori j will disclose to us some medicinal or dietetic agent, that will cut 
short the typhous fevers, or at least greatly contribute to that result. 

I think we ought not to wonder at the protracted course of the typhous 
fevers, if we grant what I think cannot be denied,— a combined lesion of 
the innervation and the blood; for what organ, what vital force extrinsic 
to them is there, to right them up, when they are cast down ? In them 
reside the sustaining and restorative energies of the whole organism ; and 
it is but reasonable to suppose that when they are both impaired, the pro- 
cess of functional reparation, the work of recuperation, must of necessity 



INTERIOR VALLEY OF NORTH AMERICA. 511 

proceed slowly, and be accomplished at periods exceedingly various. In 
cases in which these two pathological conditions exist in a high degree, 
there is no rally of the forces of the system, and early death occurs, without 
anatomical lesions. In protracted cases the recovery is gradatim, and 
always takes place under the use of tonics and stimulants, which address 
themselves to the nervous system, and nourishing food, which affords a 
supply of new and healthy blood. 

4. But there are other reasons still for the continued obstinacy of these 
fevers. The signal failure of the capillary circulation, with the consequent 
formation of passive hyperaemias and subacute inflammations in the vital and 
governing organs, cannot fail to co-operate in the resistance which the typhous 
diathesis makes to our treatment, while they constitute a chief element of 
danger in protracted cases. Every pathologist who admits them to be effects 
and not causes of the fever, will also admit the difficulty of reaching and re- 
moving them. Meanwhile they react perniciously on the morbid conditions 
of the general system which gave them birth, and which are of a kind that 
renders the ordinary remedies of inflammation improper. Some of these in- 
flammations speedily generate organic lesions, as solidification of the lungs, 
softening of the spleen, or ulceration of the glands of the ileum, with suppu- 
rative inflammation of the mesenteric ganglia, which still further complicate 
the pathology of the case, and increase its obstinacy. It is worthy of remark, 
as contributing to the difficulties which these fevers present to the physician, 
that the various organic lesions which have been mentioned are frequently 
established so insidiously, that the process is not discovered during life, or 
until too late to arrest it. 

Having taken these brief views of the inefficiency but not inutility of 
treatment in the typhous fevers, we must proceed to consider what can be 
done to moderate them, and secure a favorable termination. 

\ 



SECTION II. 

TREATMENT IN THE FORMING STAGE. 

I. The forming stage of the typhous fevers presents much diversity. 
When one of them prevails in a malignant form, such as that which has 
been called typhus petechials, the onset is generally sudden, and an oppor- 
tunity of doing anything to arrest the full and fatal development of the dis- 
ease is scarcely presented. On the other hand, those which commence with 
that kind of acuteness which affiliate them in symptoms with the phlegmasiae, 
present but a brief period of depression, and the physician seldom sees them 
till the stage of reaction is established. In the greater number of cases, 
however, especially in those which are nosologically known as typhus mitior 
and typhoid affection, or by the older writers, as nervous fever, the access 
is insidious, indefinite, and protracted through many days ; sometimes ap- 



512 THE PRINCIPAL DISEASES OF THE 

parently through several weeks, thus affording an opportunity for attempting 
something to arrest the forming malady. 

In such cases, regard should be had to the circumstances under which 
the patient has been or is still living, as they may be the causes of the 
fever, and while they continue to act, will render all prophylactic mea- 
sures powerless. 

1. Thus if he have subsisted on unhealthy or innutritious food, which 
rarely happens in this country, that which is salubrious should be supplied. 
If the appetite of the patient, as sometimes happens, should be unimpaired, 
a reduction in the amount and complexity of his food will be indispen- 
sable. 

2. If he have lived and lodged in a foul, crowded, and unventilated room, 
he should be immediately removed from it, and placed in a dry, pure, and 
temperate atmosphere. 

3. If he should be in a family or a hospital where cases of the fever al- 
ready exist, a separation from them is indispensable, notwithstanding the 
apartment may be clean and well aired. 

II. Of positive hygienic agencies, one of the most important is the 
application of cold water to the skin. Its capillary circulation, perspi- 
ratory function, calorific function, and sensibility, are always impaired 
in the forming stage. The cutaneous nerves are the chief seats of 
the sensibility to caloric, and are therefore especially susceptible to the 
sudden impress of cold water. When reaction does not take place, it may 
be promoted by rude frictions, or in extreme cases, by an antecedent or 
subsequent hot bath continued for a short time. Under the cold dash, the 
functions of the skin are restored or improved, and the contractility of the 
whole muscular system acted on. Indeed the depressed and degraded 
innervation is thus reached, when, perhaps, no other therapeutic agent 
could affect it. The results of this treatment are not always satisfactory, 
yet it should never be omitted, when the circumstances of the case admit 
of its being employed. 

III. Among agencies decidedly medicinal, an emetic is the best. Few 
things extend their influence throughout the organism more decisively than 
full vomiting. An emetic is an alterant, and its operation is very generally 
followed by an improved condition of the contractility and sensibility of the 
organism at large. If it should be followed by an evacuation of the exist- 
ing contents of the bowels, so much the better ; but copious purging should 
be avoided. 

IV. The bath and the vomiting or either of them prepares the way for 
another process which may complete the arrest of the forming disease. I 
refer to sweating, to which both these measures predispose. To promote 
the function of the skin, the patient, who often keeps on his feet in the 
early stages of a typhous fever, must be put to bed and plied with sudorifics. 
Should he be thirsty, and not have taken an emetic (to render cold water 



INTERIOR VALLEY OF NORTH AMERICA. 513 

dangerous), he may swallow repeated draughts of that fluid, which will 
often bring on perspiration ; but after an emetic, hot drinks will be pre- 
ferable. If the nausea have subsided, an infusion of the leaves of the 
Eupatorium perfoliatum will be useful ; if he be still nauseated, an infusion 
of balm, sage, sassafras, or serpentaria, will be preferable. In general a 
gentle opiate, as five grains of Dover's powder, fifteen drops of laudanum, 
two drachms of paregoric, or a corresponding dose of sulphate of morphine, 
will allay irritation, dispose to sleep, and excite the perspiratory function. 
It is advantageous also, to combine with the Dover's powder, five grains of 
blue mass or calomel, to reinstate the commonly suspended action of the 
liver. In some cases the vital forces are so low, that more stimulating 
diaphoretics are required, then hot whiskey, or gin and water should be 
used. By whatever means this may be brought about, should a perspira- 
tion come on, it should be maintained for many hours, the longer and the 
more profuse the better. The system is not yet in a state of exhaustion, 
and the lost water of the blood is speedily replaced. Indeed it is compen- 
sated by the drinks which are administered. The sour and offensive smell of 
the perspiration which these cases often present, indicates that a real depura- 
tion of the blood is thus effected, and the reactive influence on the nervous 
system of an organ so extensive as the skin, brought into healthy function is 
highly salutary. The people themselves sometimes arrest this fever by 
" taking a sweat," which consists largely in applications to the skin. In 
the epidemic of Uniontown, Pennsylvania, Dr. Fuller saw the fever thus 
broken, by surrounding the patient with ears of Indian corn (maize), taken 
out of boiling water, hot herb teas being at the same time administered 
liberally. 

Such a perspiration cannot, however, be always excited ; it will be con- 
fined to the face and upper part of the body, or may not even appear on 
them. Under such a failure, the patient is not left in the condition he was 
before he became the subject of medical treatment; but is brought into 
the stage of reaction or full febrile excitement, at an earlier period than he 
might otherwise have reached it. This, however, does not constitute an 
objection to the method, as a protracted forming stage with a slow reaction 
is not desirable, for it is during the former that much of the mischief is 
accomplished ; whatever, therefore, brings on febrile reaction tends to sim- 
plify the case, and render it more amenable to the treatment adapted to 
the fully formed fever, to the study of which we are now brought. But 
before proceeding to it, I must say, that sufficient attention has not been 
given by the profession generally to the therapeutics of the forming, in most 
instances the only curable stage of the fever. It is that which corresponds 
to the first or diarrhoeal stage of epidemic cholera ; and although a typhous 
fever may not be as easily arrested as cholera in the first stadium, the suc- 
cess of treatment in the latter should encourage us in regard to the former. 
The therapeutics of this stage differ widely from those of the next. A 

vol. ii. 33 



514 THE PRINCIPAL DISEASES OP THE 

forming pathological condition is to be arrested, and to this end a powerful 
impression must be made on the system, as when we would change or over- 
come a vibration in a complicated machine, by a stronger raised by a dif- 
ferent agent applied in a different mode. A tender, sedative, and soothing 
method will not answer. The nervous, muscular, capillary and glandular 
systems must be aroused by their appropriate excitants, and the blood must 
be made to cast out through the latter, the matters which have become 
foreign to its constitution. To this end it is desirable that all the great 
emunctories should be excited into action. Secretion from the mucous 
membrane of the bowels is, however, too sedative and debilitating while it 
gives an inward tendency to the blood, and suspends the action of the skin, 
kidneys and liver ) secretion from the kidneys is less exhausting, but can- 
not always be excited, and is incompatible with perspiration. . Secretion 
from the liver does not prevent perspiration, nor increase the general debility, 
but in its results from the action of bile upon the bowels, tends to arrest the 
decline of the vital powers, and may therefore be advantageously promoted. 
Of all the secretions, however, that of the skin, carrying with it as is gene- 
rally the case increased secretion from the lungs and liver, is most to be 
relied upon. Indeed, I doubt whether the fever is ever arrested in the form- 
ing stage without the occurrence of perspiration. A patient who has been 
thus relieved is not to be neglected. He is somewhat in the condition of 
one in whom the fever has run a benign course and terminated by a crisis. 
He must be kept on moderate diet, take gentle tonics and restoratives, be 
preserved from diarrhoea, protected against cold and moisture, and have 
the functions of the skin and liver well supported, otherwise he may fall 
back. 

Those who believe that the diseases we are now studying are sympto- 
matic fevers, from antecedent inflammation of the brain, stomach, or ileum, 
will not of course concur in the practice here recommended. Yet apart from 
the possibility that their pathology may be erroneous, I think they might 
grant, that in the early stages of inflammations producing such constitu- 
tional lesions as exist in the typhous fevers, the remedies proposed might 
not only be harmless but perhaps the very best antiphlogistics. They should 
realize that our antiphlogistics are not all depletory and refrigerant. 

It is to be regretted, however, that from the insidious onset of many 
cases of typhus, the patient suffers the forming and almost only curable 
stage to pass by, before he sends for medical aid. 



SECTION III. 

TREATMENT OP THE EARLIER PERIODS OP THE STATE OP EXCITEMENT. 

The Stage op Excitement not Developed. — In the highly malignant 
typhous fevers, no successful reaction is established, and the disease may prove 



INTERIOR VALLEY OF NORTH AMERICA. 515 

fatal without advancing beyond the first stage. The object in such cases is 
to raise a state of excitement, and the basis of the treatment is that which 
has just been recommended for arresting the fever in the forming stage. 
When, however, the access of the disease has been violent, and the patient 
from previous good health and strength has been suddenly brought into a 
state of extreme debility and depression, it will be advisable to bleed him. 
This is not done to subdue inflammation, for it does not exist; but to 
increase the contractility of the heart, arteries, and capillaries, and if pos- 
sible to diminish the congestion of the brain, spinal cord, heart, lungs, and 
portal viscera; within the whole or a part of which, not only the quantity 
of blood due to their physiological state, but most of that which should be 
found in the extremital and parietal portions of the body, is now accumu- 
lated. This visceral plethora, the consequence of a failure in the powers 
which maintain the circulation, contributes still further to oppress those 
powers; which may thus be annihilated by the reactive influence of the 
lesions of the circulation wbich that failure has generated. The results of 
venesection under such circumstances, are uncertain. When the impulse 
of the heart is feeble and the pulse weak and empty, reaction seldom 
follows; and when whatever energy they manifest before the operation, 
they become weaker as the blood is drawn, no benefit, but the reverse, will 
result. Thus if a single bleeding should not produce reactionary excite- 
ment, no more should be attempted. But there are cases in which the 
sense of oppression and anguish, indicates that the congestion is chiefly in 
a single organ, as the brain, or those in a single cavity, the lungs and heart, 
or the epigastric viscera. In such cases cupping or leeching should never 
be omitted, and it may be resorted to when the vital forces are so much 
reduced that venesection seems hazardous, or after that operation has been 
performed without the desired result. 

Happily we do not often meet with this dangerous modification of typhous 
fever in our Interior Valley. I have not seen it since the years 1809-14, 
but in 1829, the epidemic described by Dr. Kirtland and Dr. Allen* pre- 
sented many cases of this character. They did not find bloodletting salu- 
tary, and were led to place their chief reliance on stimulation, internal and 
external. The latter should be preferred whenever the susceptibility of the 
skin remains sufficient to give efficiency to the means employed. These 
may be hot cataplasms, sinapisms, blisters, and turpentine. The parts on 
which they will produce the greatest effect are the epigastrium and spine. 
The diffusible and narcotic stimulants are not, I apprehend, the best in 
these cases, and hence, for internal administration, oil of turpentine, carbo- 
nate of ammonia, phosphorus, tincture of cantharides, and arsenious acid, 
are to be preferred. They should be given in such doses as to excite an 
early inflammatory action in the mucous membrane of the stomach and 
bowels. In the typhus syncopalis of New England, Dr. North found a 

* Ante, p. 383. 



516 THE PRINCIPAL DISEASES OF THE 

single drop of the solution of arsenite of potash, given every hour, produc- 
tive of good effects. 

The whole object of the treatment in this stage is to promote reaction, 
or bring on febrile excitement : when this cannot be accomplished, the 
patient dies j when it can, he is merely brought into the condition of those 
in which the stage of excitement is spontaneously developed, and to that 
stage we must now give attention. 



SECTION IV. 

TREATMENT OP THE EARLY PART OF THE STAGE OP EXCITEMENT. 

I. The state we are now to consider may be said to continue to the ter- 
mination of the disease ; but with a gradual decline of intensity. Thus, 
the earlier periods are characterized by symptoms of febrile and even in- 
flammatory excitement, its latter by those of adynamia and exhaustion, and 
the transition is in general gradual. In many cases, or even whole epi- 
demics, the febrile symptoms never become acute and violent, but display a 
low and obstinate character, at once suggesting and forbidding both depletion 
and stimulation. Other forms, however, designated by the terms synocha and 
synochus, in the beginning of the hot stage simulate the phlegmasia so closely 
as to intimate a necessity for the adoption of a vigorous antiphlogistic treat- 
ment. It cannot be doubted that such cases have a close affinity with the 
phlogistic fevers, and some of them are undoubtedly arrested by the treat- 
ment adapted to that group. A greater number, however, are but moderated 
in their inflammatory aspect, and continuing, very soon display symptoms 
essentially characteristic of the typhous diathesis. As no method of 
promptly or certainly correcting this diathesis, and terminating the con- 
gestions and sub-inflammations which attend it, has yet been discovered, 
we cannot lay down indications of cure, and class our remedial measures 
accordingly, but must treat of individual remedies and their union, accord; 
ing to the lights of experience, endeavoring, at the same time, to estimate 
on physiological principles, the modus operandi of each. I shall begin 
with — 

II. The Hygienic Management. — Whatever may be the grade of 
febrile or phlogistic excitement, a strict attention to hygienic regulations is 
indispensable. The hair of the patient should be cut close, and he should 
be kept recumbent on a straw, husk, or hair mattress, a water-bed, or a 
mere sacking-bottom; his bed-clothes should be changed daily; no part of 
his body not usually exposed to the air and light should be left naked, but 
the covering should be of the lightest kind in summer, and at no season 
heavier than is necessary to prevent any part of the surface from becoming 
cold. Whenever the temperature of the feet may fall below the natural 
standard, and whether that of the head rise above it or not, it should be re- 



INTERIOR VALLEY OF NORTH AMERICA. 517 

stored by hot, stimulating baths, or dry heat with frictions and non-con- 
ducting socks or stockings. The patient should never be allowed to lie in 
his flannel, and his linen ought to be changed every day;* the temperature 
of his chamber should be that which is most agreeable to those who are 
around him in health, as free ventilation is of the utmost importance ; when 
the weather is cool, the doors and windows should not be closed, so as to 
render the room comfortable, but kept partially open (not, however, so as 
to throw a current of air upon the patient), and the heat of the room main- 
tained by an open fire, much to be preferred to a stove, as less offensive in 
its radiations, and more promotive of ventilation. The chamber should 
not be darkened, but reduced to a dim or subdued and uniform illumina- 
tion, and no stream of light, either from window or lamp, should be allowed 
to fall on the eye. The walls should be divested of paintings, and bright 
papering, especially that of complex figures, should be covered over, for the 
sight of it sometimes brings on or promotes delirium. All loud, shrill, or 
tumultuous noises should be abated, and audible reading or continued con- 
versations in the chamber should be prohibited ; and, on the other hand, 
whispering should not be practised, as the patient is apt to become excited 
and perplexed by unsatisfied curiosity. He is never injured by the degree 
of light and sound which are necessary to a clear perception of all that is 
to be done or said in his chamber, and the more intelligible everything is 
made to his observation the better. He should not, however, be conversed 
with, except in relation to his wants and the means of cure ; business 
affairs should not be allowed to occupy his mind or excite his feelings, and 
all persons but those commissioned to wait upon him should be excluded. 
If his appetite should not be suspended, he should be kept on an antiphlo- 
gistic diet through the earlier stages of the fever, but as it advances, a 
larger allowance, as we shall presently see, will not only be safe but neces- 
sary. All exciting beverages should, through the early period, be withheld, 
but water may be allowed ad libitum. Finally, I would complete the hygienic 
formula by suggesting a daily alvine evacuation at the usual hour, procured 
by an enema; an attention to the regular evacuation of urine, and the pre- 
servation of a clean skin and mouth by frequent ablutions. The former 
should, indeed, be subjected to repeated washings, sponging, or effusions of 
cool or subtepid water, the revival of fever-temperature being the index, as 
it is the reason for the repetition. 

The circumstances which have been pointed out, or most of them, are 
necessary to the successful treatment of a remittent autumnal fever, or one 
of the acute phlegmasia, as cerebritis or pneumonia, but they will not of them- 
selves effect a cure. It remains, however, to be decided by experiment, 
whether a typhous patient might not be more safely trusted to such a regu- 
lation, of what our predecessors called the non-naturals, than to enfeebling 

* I have scarcely ever been called to a student of medicine ill with fever, who was not lying in his 
flannel. Such habits show those of the families to which they belbng. 



518 THE PRINCIPAL DISEASES OP THE 

and perturbating medication, with the neglect of them which we so often 
see in practice. I will even venture a step further, and query whether this 
fever, which has hitherto in the main held its course in despite of the 
Materia Medica, would not, when simple, as often terminate in health under 
such circumstances, without as with the other means which we are taught 
to employ ?* Upon those means we must now successively direct our 
attention. 

III. Bloodletting. — General bloodletting is never employed but in the 
earlier stages of the typhous fevers ; but local bleeding is held to be admis- 
sible in every stage. A great majority of the cases of typhous fever in our 
Valley do not present a stage of excitement that demands, or even justifies, 
the use of the lancet, and most of the physicians, whose histories are em- 
bodied in this article, have employed it sparingly or not at all. There are 
cases, however, if not epidemics, which seem to demand it. A sudden 
attack, a previously vigorous constitution, middle life, and a sanguineo- 
bilious temperament, although there may be no inflammation developed, nor 
any actual hardness of the pulse, render it proper at the beginning to 
diminish the fulness of the bloodvessels. One liberal bleeding is generally 
sufficient. Every medicine which is afterwards administered will produce 
its wonted effect more successfully after such a reduction of the volume of 
the blood. 

Another pathological condition, however, more imperatively calls for that 
remedy. With the rise of the hot stage, or soon after its establishment, 
an inflammation of the brain or its investments — of the lungs — of the 
mucous membrane of the stomach and duodenum, or of the lower extremity 
of the ileum, may manifest itself by unmistakable local symptoms, and 
a phlogistic hardness of the pulse. A full bleeding is then demanded. 
The blood will be sizy, and a repetition of the operation is sometimes 
called for. The case assimilates closely to the phlegmasia^, and requires a 
similar treatment. It can never, however, be carried to the same extent. 
There is not a simple hyperinosis of the blood, a true phlogistic diathesis, 
but an inflammatory, typhous diathesis ; the former element may be mode- 
rated by the loss of blood, but the latter cannot, and if the bleeding should 
be carried too far, it will be augmented. When, however, the energy of 
the pulse keeps up without increase of frequency, the fur of the tongue 
retains its whiteness, and neither coma nor subsultus tendinum begin to 
supervene, should the local symptoms still exist, a further and free resort to 

* In an age and country like my own, where a liberal administration of medicines is expected by 
patients and regarded as a duty by physicians, the suggestions which have been made are not likely 
to inspire any dangerous reliance on the medicine expectante, and may even do good, as far as they have 
influence with any, by diminishing tbe officious and relentless efforts of art, directed in a different 
way. It is, in the author's opinion, desirable that in cities where fever hospitals place patients under 
the control of physicians and nurses, the experiment should be made of a purely hygienic method. If 
attempted, one thing should be added, namely, some inert substance, supposed by the patient to be 
medicinal, that he might have a definite means of cure on which to fix his imagination, and rest his 
hopes. 



INTERIOR VALLEY OF NORTH AMERICA. 519 

the lancet may be practised ; for such a case, whatever might have been the 
first diagnosis, now belongs to the phlegmasia, and will only yield to the 
treatment which they require. 

In the more advanced stages of typhus, when the symptoms of that 
fever are well developed, the lancet sometimes is, or seems to be, indicated. 
Here again the inflammation of some vital organ, especially the brain or 
lungs, creates the supposed necessity. In this dilemma the patient may 
die from speedy disorganization of the affected viscus, if he be not bled; and 
if bled, he may sink exhausted. Even the suffering organ may still remain 
in a state of congestion, though the active molecular movements of inflam- 
mation may not be going on. Such cases, when they occur, must be left to 
the sagacity of the physician who is so unfortunate as to encounter them. 

The questions which topical bleeding presents are less perplexing than 
those we have considered. There are not many cases of any form of 
typhous fever, nor any stage except the closing, in which it is not required, 
or at least may not be safely employed. Of course the object at all times 
is to relieve some organ from congestion or inflammation. In the milder 
cases it will do this (as far as the loss of blood can go) without a previous 
resort to the lancet ; and in the more violent and phlogistic forms, it is 
admirably fitted to complete the venesection began. Finally, in such cases, 
just described, as are ambiguous, a resort to it, if practicable, may often 
relieve the physician from his embarrassment. 

By a reference to the historical portion of this article, Chap. III., where 
condensed accounts of the practice of more than thirty of our physicians are 
given, it will be seen that, like their European brethren, while they agree 
as to local bleeding, they differ in their estimates of the value of general 
bloodletting. Most of them had not employed it, several had given it a 
trial in a few cases, and found it injurious, or at least useless j others had 
repeated it in the same patient, but a greater number had used it once only 
in each case. On the whole, the weight of testimony, much of which, how- 
ever, is negative, lies against the use of the lancet. It may, I think, be 
assumed that one bleeding in the earlier stages, will, in many cases, do no 
appreciable good or harm. 

IV. Emetics. — In all times and places, emetics have been more or less 
employed in typhous fevers. With my own preceptor, the late Dr. Go- 
forth, who received his medical education in New York, in the last century, 
they were a favorite remedy, and, taught by him, I have at all times been 
accustomed to prescribe them. His formula was a compound of tartarized 
antimony, ipecac, and powdered valeriau root. I know not that the anti- 
spasmodic exerted any influence ', but in considering its use, we should not 
forget the peculiar state of the nervous system in these fevers. 

If bloodletting seem to be demanded, it should be employed first, and the 
sooner the emetic is administered afterwards, the better will be its operation. 
Great fulness of the bloodvessels may be regarded as contraindicating the 



520 THE PRINCIPAL DISEASES OF THE 

emetic; but gastritis constitutes a still stronger objection, and a careful 
inquiry into the state of the stomach should precede the decision in favor 
of that remedy. An accurate diagnosis, however, is not always practicable; 
for both epigastric tenderness under pressure and redness of the edges of the 
tongue, may exist without gastritis. I do not believe that this inflamma- 
tion is a frequent accompaniment of our typhous fever; for I have seen 
emetics very often given with advantage, or at least impunity, when the 
symptoms just mentioned were present. During the temporary and partial 
reign of Broussaism over the physicians of the Valley, gastro-enteritis had 
a corresponding prevalence; at present we hear little of it, but much of 
ileo-ccecal embarrassment. The finger of diagnosis is turned from the 
epigastric to the iliac region. 

An emetic unloads the stomach, often oppressed and irritated by undi- 
gested food and unhealthy secretions, to the reactive impress of which we 
may ascribe, in part at least, the morbid sensibility of that organ. The close 
contraction of the muscular tunic presses the sluggish or stagnant blood 
out of its capillary vessels. The nausea and the act of vomiting, reduce the 
powers of the heart and nervous centres, but predispose them to more ener- 
getic and normal action ; and thus the pulse generally acquires greater fulness 
and force, and the innervation at large displays a healthier character. If 
the lungs are in a state of engorgement, or languid transmission of blood, 
or the bronchial tubes should be obstructed with unexpectorated mucus, con- 
siderable relief is obtained. If the portal viscera be engorged, their com- 
pression by the diaphragm and abdominal muscles impels the blood onward. 
Finally, as all experience teaches, the skin is reached, improved in its 
circulation, and disposed to perspiration. Every part of this may be tem- 
porary ; but whatever exerts even a transient beneficial influence, without 
subsequent injury, should be regarded with favor, in a disease which only 
admits of palliation. As sleep, and a tendency to diaphoresis, generally 
follow the operation of the emetic, it should be administered in the evening, 
and followed by gentle sudorifics, with a moderate portion of some prepara- 
tion of opium to calm the agitation of the nervous and muscular systems ; 
and this administration will be especially advisable when there are appre- 
hensions of gastritis; for by allaying the irritation of the stomach, that 
medicine will render the action of the emetic less injurious in reference to 
that disease. As to the repetition of the emetic no rule can be written 
down. In many cases a single one may, perhaps, confer all the benefits 
which vomiting can afford ; but in the absence of gastritis, I am persuaded 
it may in many cases be repeated with advantage, especially when the con- 
gestion of the brain is little and that of the lungs great. 

It appears from the histories which have been given that many of our 
physicians have prescribed emetics, but with varying and doubtful results. 
They have often brought on diarrhoea, especially when composed of tartarised 
antimony. In the early periods of the hot stage, their action on the bowels 



INTERIOR VALLEY OF NORTH AMERICA. 521 

is not always injurious. But it is possible to administer an emetic when 
the bowels are irritable, without exciting their peristaltic action. This is 
done by administering a full dose of opium at night and the emetic early in 
the morning, to be followed in the decline of its operation by another opiate. 
When an emetic is so managed as not to purge, it generally restrains diar- 
rhoea. The antiperistaltic action extends to the bowels in such a degree as 
to arrest, but not invert their muscular movement. It is not indispen- 
sable, however, to employ tartar emetic, and when diarrhoea exists, ipecac. 
or lobelia inflata may be substituted. Whatever is used should be given in 
such doses as to vomit promptly, by which the danger of purging will be 
diminished. 

V. Emetic Medicines giyen as Alterants. — The administration of 
emetic medicines in nauseating or subnauseating doses has found more 
favor with the profession generally than their exhibition to full vomiting. 
When the powers of the system are greatly reduced, or the bowels are irri- 
table, ipecac, has been chosen ; it is easy, however, by the addition of 
opium, to render tartarized antimony quite as harmless, and I cannot doubt 
that as an alterant and secernent, it is superior to ipecac. The exhibition 
of some antimonial preparation in these fevers is a practice which belongs 
to the profession. Discussions have sometimes arisen whether they should 
be administered in nauseating doses. I have found the best administration 
to be that which the stomach can perceive, but under which it does not 
suffer. Minute doses are in general sufficient; for the tolerance of this 
medicine, which exists in some of the phlegmasise, is here absent — a thera- 
peutical proof of pathological difference. The cases of fever in which I 
have found tartarized antimony most beneficial, are those which the nosolo- 
gists call synochus, and those in which there are pulmonary complications. 
When the typhous diathesis is fully developed that medicine does less good, 
and, as already intimated, may do harm. Tartar emetic, slowly and perse- 
veringly administered, establishes in the system an impression of its own, 
an antimonial action, under which the febrile action often gives way. At 
the same time, it exerts over the heart a sedative influence, which is espe- 
cially important in cases which seem to require the lancet. It relieves 
pulmonary congestion, and increases bronchial secretion and expectoration. 
Finally, it acts upon the skin, and assists in re-establishing its functions. 

The manner of its administration is, perhaps, not unimportant. I have 
generally given it in the common saline or neutral mixture, each portion 
consisting of half an ounce, containing from the fourth to the eighth or 
tenth of a grain of the antimonial, every two hours, according to the degree of 
arterial energy and the idiosyncrasy of the patient. Dr. Gordon, as we have 
seen, has administered it in connection with minute, or non-purgative doses 
of sulphate of magnesia, with decided success. Indeed, he ascribes the 
greater part of the benefit to the sulphate, which he has given in five-grain 
doses, without the antimonial, and with happy results. When entered 



522 THE PRINCIPAL DISEASES OP THE 

upon, it should be continued day and night until the fever abates, or the 
aspect of the case indicates that its effects are unfavorable. Such indica- 
tion being given by the increasing irritability of the stomach, augmented 
frequency of pulse, and greater restlessness. 

In cases to which it has a doubtful applicability, the spiritus Mindereri 
may be substituted for the less stimulating saline mixture, and a small 
quantity of laudanum, paregoric, or the acetate of morphia, should be 
added. The greatest objection to the tartar emetic solution is, perhaps, 
its tendency to excite the bowels ; but here again it may be generally re- 
strained by the addition of some preparation of opium — laudanum probably 
being the best. Such an addition cannot be injurious; for the cases in 
which the bowels are most irritable are least complicated with inflammation 
of the brain. The propriety of allowing cold drinks during the administra- 
tion of this medicine is doubtful. It seems to induce a state of the stomach 
which renders that organ intolerant of cold draughts. This is unquestion- 
ably the case when it is administered as an emetic; for I have known two 
men destroyed by that indulgence, and in the third the production of a 
gastritis, which required the loss of a large quantity of blood for its 
subdual. 

VI. Cathartics. — The testimony of our physicians, as far as I have 
become acquainted with it, is undividedly against active purging. When- 
ever promoted its effect seems to have been to lower the vital powers, and 
bring on increase of diarrhoea without removing a single symptom of the dis- 
ease. In proportion to the feebleness of reaction is the injurious effect of 
purgation. I am happy to say, that none of them have fallen into the 
plan of allowing the bowels to remain costive from the beginning ; and 
therefore none of them have reported the discharge of scybalse in an ad- 
vanced stage of the fever. We may, I think, feel assured that in every case 
of typhus, it is proper in commencing the treatment to evacuate the existing 
contents of the bowels not less than the stomach ; and almost equally pro- 
per to guard against any great and long-continued accumulation of fecal 
matters or morbid secretions afterwards ; but in both cases the operations 
should be limited to such evacuations. The mischief is done by their 
greater operation, which sinks the patient's strength, gives an introversion 
to the circulating blood, and when there is an affection of the glands of the 
ileum, contributes to aggravate it. Dr. Smith* informs us, that he had 
generally seen patients recover who were costive throughout the fever; but 
did their recovery result from their costiveness ? Such cases I am disposed 
to think are in general the least dangerous, and in that may perhaps be 
found in part the reason of the favorable termination. I am not, however, 
either from therapeutic principle or experience, an advocate for any greater 
administration of cathartic medicines in these fevers, than is indicated in 
what has just been said. The earlier in the attack and the higher the tone 



INTERIOR VALLEY OF NORTH AMERICA. 523 

of febrile action, the greater will be their benefits. In every stage of the 
disease, however, but especially in the earlier, an actual inflammation of 
the brain will demand increased alvine evacuation. Such a pathological 
condition, I presume, seldom co-exists with diarrhoea. But how shall we 
distinguish between simple febrile congestion and positive inflammation ? 
The problem is perhaps one of the most difficult in diagnosis. The autopsic 
inquiries into the typhous fevers which have been made in Europe and 
America, within the last twenty years, have shown that true inflammation 
of the brain or its envelops, is much rarer than was once supposed; and 
taught us that delirium, coma vigil, contracted pupil, a red eye, and sub- 
sultus tendinum, may exist without inflammation ; yet they are present in 
that pathological condition. The greater force of the pulse, a firmer throb 
of the external carotids, less drowsiness, wilder delirium, and greater de- 
velopment of heat in the scalp and face, with a tendency to coldness of the 
feet, may be taken perhaps as proofs of inflammation, especially if the 
bowels be costive. To these I may add if the patient be bled until syncope 
is approaching, the absence of perspiration on the forehead and upper lip. 
This, however, like the appearance of the blood, presupposes the diagnostic 
decision to be made; yet such aids, in difficult cases, must not be rejected. 
Cerebral inflammation actually existing, and the fever not yet far advanced, 
the revulsion produced by active purging will be found an important means 
of relief. On the other hand, the cases which are complicated with a de- 
cided lesion of the glands of the ileum are those in which such a practice is 
most contraindicated. 

Our physicians, generally, with great propriety reject both the irritating 
and hydragogue cathartics. The former on account of the condition of the 
mucous membrane and its glands, the latter on account of the low state of 
the vital forces of the system at large. Calomel or the blue-mass, or the 
latter rubbed down with chalk (liyd. cum cret.), is very properly employed 
by all ; but in what for the Interior Valley are small doses, that is, from 
two to six or eight grains of either of the two former. We have perhaps no 
cathartics which irritate less, act more sparingly on the secretory apparatus 
of the mucous membrane, are followed in their operation by less exhaus- 
tion, or more seldom produce hypercatharsis. These are negative excellen- 
cies of a high order; but the mercurial preparations perform a positive 
benefit, by arousing the liver into action, and thus giving to the collatitious 
viscera all the aid which arises from their association with that organ in a 
(temporary) normal condition, instead of their continually sympathizing in 
its torpor.* 



* I know of no writer who has so distinctly pointed out the beneficial influence of righting up or 
re-exciting the normal function of an organ, upon the other organs of the same group, as the late Dr. 
Robert Jackson of the British Army. His little work on the fevers of Jamaica and some portions of 
the United States, a model of its kind, fell into the author's hands as far hack as the year 1804, when 
new works, or medical hooks of any kind, were as rare in the West, as many other fruits of civilization ; 



524 THE PRINCIPAL DISEASES OF THE 

But still further, the bile is a natural stimulus of the bowels, which fall 
into torpor and morbid secretory action whenever it is withheld ; and its 
restoration to those organs, even at intervals, in the typhous fevers, cannot 
fail to be salutary to them, and through them to other parts of the organism. 
Finally, when the function of the liver is impaired or suspended the ele- 
ments which it carries out of the blood are retained, and contribute to its 
empoisonment and the depression of the innervation. 

With these views, we are prepared to appreciate the value of mercurial 
laxatives in the typhous fevers ) but we must not expect to maintain an 
unabated secretion of bile in all cases, for the liver participates in the patho- 
logical condition of the organism generally, and having a certain degree of 
periodicity in its secretory function, will at times fall back into a state of 
quiescence, in despite of a continued administration of mercurials. 

But as aperients, these medicines sometimes fail, especially when they 
fail as cholagogues, and it becomes necessary to aid them with medicines 
more decidedly opening. In the early and more acute stages of the fever, 
the carbonate or sulphate of magnesia, the latter alone, or combined with a 
weak antimonial solution, will be proper; but in the more advanced periods, 
rhubarb, or an emulsion of castor oil and spirit of turpentine, should be 
preferred, — all of these being administered in gentle doses, and their exces- 
sive operation checked by an opiate. In place of these, however, emollient 
and slightly purgative enemata may be resorted to with advantage. These 
are thought to be especially required when constipation coexists with lesion 
of the glands of the ileum, — a rare union, — and there can be no objection 
to relying upon them in connection with mild mercurials, if they be thrown 
up so far as to secure an adequate evacuation of the lateral cells of the colon. 
When the brain is inflamed, large injections are peculiarly proper, from the 
physiological relations between that organ and the rectum. 

As to the frequency of evacuation in these fevers, I would say that when 
purgatives are administered, two or three operations are sufficient, and that 
in the absence of diarrhoea, an evacuation once a day or once in two days, is 
as much as should be desired. 

VII. Mercurials as Alterants. — The amount of calomel or blue 
mass required to excite the liver and bowels, will not in general affect the 
system at large or produce salivation. Calomel has, therefore, been admi- 
nistered to the production of a mercurial diathesis. I have in former times 
given it with that view, and many other physicians of the Interior Valley 
have done the same. By this treatment, the condition of the patient has 
sometimes been improved, but I have never seen the fever arrested, and the 
mercurial irritation has not unfrequently seemed to blend itself with the 

and the perusal of it made an impression which remains to this hour, in union with a feeling of respect 
and thankfulness, that insists on being recorded. The few physicians who, at that time, were students 
in the wilderness, must have recollections that will lead them to pardon this personal reminiscence, 
should it perhaps justly be regarded as in doubtful taste by younger members of the profession. 



INTERIOR VALLEY OP NORTH AMERICA. 525 

typhous, making the condition of the patient worse instead of better. A 
benign salivation, moreover, very seldom occurs, but in its stead the gums 
assume a flat and pallid aspect, with patches of white curdy deposit or epi- 
thelial slough, and at the same time eschars, terminating in ulcers, appear 
on the inside of the lips and cheeks. Such a result of the mercurial treat- 
ment is greatly to be deprecated, as it is not merely a sign that no good has 
been done, but a condition induced which may greatly increase the sufferings 
of the patient, and even add to his dangers by the sloughing or gangrenous 
tendency of the sores. The practice of giving calomel in alterant doses in 
the typhous fevers, has long since been renounced by myself, and very few 
if any of our physicians now follow it. 

Calomel, when thus administered, is capable of making itself extensively 
and powerfully felt, but the diathesis it establishes cannot set aside the 
typhous diathesis, nor even afford the mitigation which so often comes from 
the antimonial diathesis. This might have been inferred from two facts, 
first, the injurious effects of a mercurial irritation in scorbutus, between which 
and the typhous diathesis, as we saw in the last chapter, there are some 
close affinities; second, the controlling power of calomel over the acute 
phlegmasia, especially those of the serous membranes, in which the dia- 
thesis is phlogistic ; the opposite, in many respects, to that of the typhous 
fevers. 

We cannot, however, entirely discard this medicine in the fevers we are 
now studying, for in several states and complications, there is that approach 
to the phlegmasiae, which justifies or requires its administration. First, in 
the early stages of the cases denominated synocha or synochus, when there is 
a white tongue, a bounding if not tense pulse, acute pains of the head, back, 
or limbs, and subsultus, delirium, and coma have not set in, the impress of 
calomel is safe and beneficial, though it may but seldom terminate the fever. 
Second, if the membranes of the brain become acutely inflamed in any stage 
of the fever, but especially in the earlier, calomel may be freely adminis- 
tered. Third, the rise of an acute mucous gastritis will imperatively de- 
mand a free and repeated administration of calomel, combined with opium. 
Fourth, the occurrence of hepatitis will equally require an unrestricted resort 
to that medicine. The therapeutic principle then is, that calomel as an 
alterant is useful in the typhous fevers in proportion as a primary or con- 
tingent hyperinosis or phlogistic state may arise j and when we connect the 
good it has done in these conditions, with the benefits of its action on the 
biliary system, we can understand how it is that with some physicians there 
is a leaning towards its employment in every case. 

VIII. Sudorifics. — No physician treats the fevers we are now studying 
without the exhibition of sudorifics. The recovery which almost invariably 
follows on a general warm and prolonged perspiration, has established in 
our minds an association of ideas between that function restored and the 



526 THE PRINCIPAL DISEASES OP THE 

restoration of the patient, which prevents our inquiring how they stand re- 
lated as cause and effect. We aim as earnestly to produce the desired phe- 
nomenon, as if we actually knew that it would be the cause of what it may 
be only the sign, — the approaching convalescence of the patient. Passing 
this by, however, we may grant that the sudorific treatment has much to 
recommend it of both theory and results, and should therefore receive atten- 
tion in every case. Nevertheless, in the stage of the fever now under con- 
sideration, we are not to administer sudorifics in the doses and with the ex- 
ternal adjuncts which are admissible in the forming stage. A gentler and 
more prolonged administration is required, nor should we aim or expect to 
bring on a perspiration in that portion of the twenty-four hours which ex- 
tends from noon to midnight, for the febrile excitement is generally greater 
then than from midnight to noon. It is not uncommon for a perspiration 
to begin on the face and upper parts of the body, and on successive days to 
extend gradually to the feet. This is favorable ; but when it continues 
limited to the upper portions of the body, the prognosis is not so good, 
especially, as sometimes happens, if the lower extremities should lose their 
natural temperature. 

In the early stages of the fever (which we are now especially considering), 
the saline and sedative sudorifics are most proper. The antimonial solution 
which has been named, may be regarded as one of the best; but as it is in- 
dispensable to a tangible perspiration that the bowels should be quiet, the 
pulvis antimonialis or ipecac, in minute doses, is, perhaps, preferable. 

The former has never been extensively used in the Valley, but the latter 
is employed by most of our physicians. Of their comparative powers, I 
cannot speak from experience, having seldom employed the antimonial. 
When the febrile excitement is considerable, several saline substances, as 
the acetate, nitrate or citrate of potash may be advantageously given ; the 
various diaphoretic infusions already mentioned should be administered as 
freely as the stomach will bear, and sometimes throwing all medicines aside, 
large draughts of cold water — should the patient crave and relish them — 
will effect the desired end. As a general fact opium or its preparations 
should be combined with our sudorifics, but its administration must be 
limited to the evening or early part of the night, that the slight narcotism 
which it should produce may come on in the latter part, when perspiration 
is most likely to occur. When opium is to be given the compound powder 
of ipecac, or Dover's powder, is our best preparation; but paregoric or 
laudanum and the wine of ipecac, may be given in a solution of the nitrate 
of potash, or in the ordinary camphorated mixture. The salts of morphia 
are preferred by some of our physicians, but I have not investigated their 
claims to superiority. 

IX. Sulphate of Quinine. — The great value of this medicine in our 
periodical fevers, which sometimes terminate in secondary typhous, has led 



INTERIOR VALLEY OF NORTH AMERICA. 527 

to its employment in our continued fevers. The results have not been 
favorable. It has, at least, not been successful. Its impress cannot correct 
or supersede the typhous as it does the malarial diathesis. It may, perhaps, 
be advantageously combined with sudorifics (being one itself), when the 
excitement is low ; but should not be exhibited in the doses and with the 
views that we give it in autumnal fever. There are mixed cases, however, 
to which it is well adapted. In paludal districts typhous fever often dis- 
plays a remittent type, when, although, this medicine may not manifest the 
same controlling power as in unmixed periodical fever, it is so useful that 
the physician should not withhold it. Of what value is it in the lesions of 
the spleen so often present in the typhous fevers ? Analogy would suggest 
its employment, but I have no facts from which to draw an answer to the 
question. 

X. Organic, Vegetable Acids. — If I am not mistaken, patients have 
a keener instinct towards acidulated drinks in the typhous than the phlogis- 
tic fevers j and until delirium or coma renders them indifferent, they covet the 
application of vinegar to the skin, and its vapor to the Schneiderian mem- 
brane and lungs, which they find acceptable and refreshing. Are we at 
liberty to infer from this propensity that acids are salutary in these fevers ? 
Experience answers affirmatively. The most important organic acids are 
the acetic, tartaric, citric, and malic, existing singly or associated, in various 
summer fruits, as the tamarind, grape, lemon, apple, crabapple, currant, 
plum, and strawberry, blackberry, and gooseberry. It is worthy of remark, 
that these fruits are all nutritious, grow most abundantly in the lower lati- 
tudes, and ripen in summer. They seem designed, therefore, to counteract 
the effect of great external heat; and without inquiring whether they do it 
by supplying oxygen to the blood, and thus diminishing its absorption by 
the lungs, we are required by observation and experience to concede to 
them a cooling influence. They also supply carbon and hydrogen, which 
it is the office of the lungs to eliminate in the form of carbonic acid and 
water, but may not these elements pass off by the skin, which in hot climates 
secretes more copiously than in cold ? An increase in the sebaceous secre- 
tion would require an increased supply of carbon and hydrogen, its chief 
constituents. The native African is our best specimen of man as he is 
physically moulded by a hot climate, and he presents unequivocal proofs of 
great development of the sebaceous follicles, in the polished and greasy 
aspect of his skin when in perfect health, and the excretory character of the 
cutaneous elimination is marked by its well-known odor. An abundant 
supply of these elements seems to be a want of his constitution after his 
transplantation into the temperate regions, for we find that he constantly 
prefers fat to lean meats. Their elimination by the skin continues, although 
a colder climate demands a greater supply to the lungs. But I would not 
limit the beneficial influence of the vegetable acids in typhous fevers to 



528 THE PRINCIPAL DISEASES OF THE 

their refrigerative effect ; as their action on the vital properties of the solids 
may be and probably is of a sedative character ; thus giving them additional 
power over the tumultuary movements of the circulation in the earlier stages 
of those fevers. Still further, they probably act antiseptically in and upon 
the blood, although the modus operandi may not be understood. Their pre- 
ventive and curative power in scorbutus is known to all the world j and 
we have already traced out some important sanguineous analogies, between 
the scorbutic and typhous diathesis. 

Of the comparative therapeutic effects of the different acids, but little is 
known. If any be found in particular cases to disturb the bowels more than 
others, they should be rejected. Those which act most on the secretions 
should be preferred to others. It is a popular opinion that they act on the 
kidneys more than the skin, but my own experience leads to the opposite 
conclusion. The influence of the acidulous or bitartrate of potash on the 
former has probably led to that conclusion, but the salt is decomposed and 
its alkali becomes the diuretic. Vinegar, or the acetic acid, the best for 
external use, is I think the least acceptable to the taste and stomach of the 
patient. The malic acid, not being officinal, can only be had in practice by 
macerating the fruits which contain it, when other substances, irritating to 
the bowels, may be extracted. The citric and tartaric acids, are most 
available, and every typhous patient should be supplied, ad libitum, with 
lemonade or tartarade, not made very sweet. In hospital practice I have 
found the latter cheap and convenient. The vegetable jellies, consisting of 
one or more of the acids in combination with the pectic, are eligible pre- 
parations, and when the stomach of the patient is oppressed by the fluids 
taken, they may be swallowed in their semi-solid form; which leads me to 
say that the various acido-saccharine fruits, when perfectly ripe, may in 
some cases be preferable to their insulated acids. In the treatment of the 
phlegmasiae this would not be the case ; but an ample experience has shown, 
that except in the beginning of the most inflammatory forms of typhous, 
a certain amount of nutriment should be daily administered. Great care 
should be taken, however, that the integuments, seeds, and other indigesti- 
ble parts should not be swallowed, as they might irritate the stomach and 
bowels. 

The use of certain medicines will render a liberal administration of the 
vegetable acids improper. Thus, about the time of the operation of an 
emetic or cathartic, or during an alterant course of tartarized antimony or 
calomel, they should be given sparingly; with sudorifics, however, they 
may be exhibited freely, but the water in which they are dissolved should 
not be cold. 

XI. Cold and Tepid Effusion. — Although I have referred to the ex- 
ternal application of water when speaking of the hygienic and expectant 
treatment, I must return to it here. Of its decided value in the treatment 



INTERIOR VALLEY OF NORTH AMERICA. 529 

of the typhous fever, I cannot entertain a doubt. Its application may be 
both general and topical. As to temperature it should generally be of 
seventy or eighty degrees of Fahrenheit. Throughout the early stages of 
the fever, spongings, washings, or affusions, repeatedly or frequently made, 
will lower the heat of the surface, reduce the frequency of the pulse, and 
soothe the patient if restless. When he is drowsy, with a dark red and 
cushioned cheek, the affusion of a few buckets of colder water, varying from 
fifty to sixty degrees, will often arouse and give him a natural expression. 
The sudden and decided impression on the nerves of the skin changes the 
state of his innervation generally. It must be remembered, however, that 
very cold water may be followed by a reaction that is not desirable in the 
stage of the fever we are now studying. The object is to carry off the 
superabundant heat, and moderate the morbid activity of the calorific func- 
tion, which will best be effected by water that barely feels cold. The higher 
the temperature, and the more intense the febrile action, the higher should 
be the warmth of the water, and the longer its application. If it be raised 
to the ninetieth degree, it will still, by perseverance, effect the object for 
which it is employed, without the risk of reaction. It is during the stage 
of mere functional disorder, with simple congestions, that the general laving 
or affusion is most beneficial. I even doubt the propriety of applying cold 
water to the general surface after active inflammation has become established 
in any great organ. 

For such an inflammation the topical application of water is one of our best 
remedies. I see no objection to its use when the inflammation is seated in 
the lungs, provided its temperature be subtepid or cool, but I have not em- 
ployed it. When the inflammation is established in the brain, and often 
when, as I presume, there is congestion only, its application to the head is, 
as we all know, nearly universal. For this purpose it is sometimes iced, 
and even ice itself is not unfrequently used, but we may well doubt the 
propriety of such a practice. It is, in my own opinion, far better to take 
water of the temperature of 60° or 70°. Its continued and skilful appli- 
cation will at length produce a decided effect, and reaction will not follow. 
To give it effect, it must not be applied by placing a wet and many-folded 
towel on the crown of the head, as I have seen even physicians do, while 
nurses seldom think of any other. If a fabric be employed at all, a coarse 
linen rag is the best, which should never be doubled, should cover the 
entire head, coming over the forehead to the brows, and should be removed 
and re-wet as often as it begins to feel dry. In place of such a vehicle, 
however, a wet sponge may be passed over the same surface at short in- 
tervals. In either case, fanning, or a current of air from without to pro- 
mote evaporation, will be an important auxiliary. In cases of a desperate 
character, a stream of water of the same temperature may be made to fall 
upon different parts of the head, and this is perhaps the most powerful 
mode. During applications to the head, which, if chilliness should not 

vol. ii. 34 



530 THE PRINCIPAL DISEASES OP THE 

come on, it maybe necessary to continue for many successive hours, or even 
days, the body of the patient should be kept well though not oppressively 
covered, and measures be adopted to keep the feet warm. When the brain is 
inflamed they are apt to become cold, a fact which suggests that the main- 
tenance of their temperature may diminish that of the head. To accomplish 
this object they may be placed for a brief period in iced water, and then 
immersed in a hot and stimulating bath, after which they should be briskly 
rubbed with the warm naked hand of a nurse, and then wrapped together in 
a soft blanket. The heat will be better retained when they are in contact, 
than when they are separated by woollen socks. If these rules be neglected 
in cerebral typhus, the resort to water will do little good ; but faithfully 
and perseveringly observed, great benefits may be obtained. 

In abdominal typhus, when there is decided heat of the parietes, with 
morbid sensibility or tenderness under percussion, whether in the right 
iliac region, or over a greater area, when a certain degree of fulness exists, 
and pressure creates borborygmi, whether diarrhoea be present or not, the 
application of water to the abdomen is one of the very best. It may fall 
in a stream, the patient being laid on an India-rubber sheet, or be applied 
in the other modes just pointed out; or when their weight is not oppres- 
sive, in the form of large, emollient, subtepid cataplasms, frequently re- 
newed, as was practised by Dr. Gordon. A valuable modification of this 
practice is to cover the whole anterior and lateral parts of the abdomen 
with several soft towels, thoroughly and separately wetted in subtepid 
water, and applied lightly over each other, so as to be partially separated 
by atmospheric air ; the whole to be covered with oil or varnished silk, so 
as to confine the vapor. In making these applications, it should be recol- 
lected that the spleen is often undergoing a disorganization in these fevers, 
which might perhaps be retarded by carrying the water over the left hypo- 
chondrium. It should also be borne in mind that the liver, not less than 
the alimentary membrane, may be the seat of a congestion or inflammation 
which might be mitigated by slightly acidulating the water with nitro- 
muriatic acid. In conclusion, I must recognize the rule originally laid 
down by Dr. Currie, not to continue the application of water, either general 
or local, after chilliness supervenes. 

From the earliest settlement of the Interior Valley, its physicians have 
had to grapple with — quite too often yield to — the prejudices of the people 
against the general application of water to the surface in fevers, especially 
its affusion, which in many cases is the only mode that the resources of the 
sick-room will permit. This prejudice, which evidently had its origin in 
the erroneous pathology and still more erroneous therapeutics of our prede- 
cessors, was greater formerly than at present. In this city, during the 
epidemic typhous constitution already described, which continued from 
1809 to 1813, or longer, the popular objection to the cold affusion was 
decided. During that period, the author first saw the classical work of 



INTERIOR VALLEY OP NORTH AMERICA. 531 

Dr. Currie on this subject, and sought to carry out his advice, but it met 
with serious opposition. To mitigate its obstinacy, he published in one of 
the papers of the Tillage, an account of several cases successfully treated 
with cold affusion as one of the remedies, and thus producing a temporary 
impression on the public of a favorable kind, procured him the opportu- 
nity of making the application in a sufficient number of cases to be assured 
of its value. It has remained, however, for empiricism to achieve what 
science cannot, the destruction of one of its own errors engrafted on the 
popular mind ; and if hydropathy should continue in vogue long enough to 
overcome the fears of the people in regard to the application of water in 
fevers, it will do something to compensate for the injury it has done, by 
an excessive application of that fluid in diseases to which it was not adapted. 
XII. Blisters. — Counter-irritation with blisters should not be made to 
arrest or moderate the fever, but to relieve particular organs. The former 
it cannot accomplish, but the latter is within its reach. Blisters should 
never be a first remedy if the febrile excitement run high, as it is well 
known that they will then torment the patient without conferring any 
benefit, and may even aggravate the fever. The limitation of their use is, 
I think, better understood in the Interior Valley now than in former times. 
When they are applied it is for the relief of inflammation; but a common 
error prevails by which their benefits are diminished, — they are kept back 
too long. To be effective, they should be applied while the inflammation 
is still in its forming stage. Up to the time of its full establishment, the 
disease of the organ may be said to be merely functional, but after morbid 
secretion of the lymphatic or purulent kind has commenced, the counter- 
irritation cannot be expected to effect a resolution of the inflammation. 

When the inflammation is seated in the brain, it is the common practice 
to apply the first blisters to the ankles ; but as there is always a possibility 
of gangrene in the typhous fevers, it is more proper to apply them to the 
insides of the thighs. The next is generally applied to the nucha and 
occiput, and I can see no reason why the first should not be there. The 
last (in cerebral typhous) is to the scalp, which is generally deferred to so 
late a stage of the fever as to be useless. This postponement till the death 
of the patient is at hand, has established in the minds of many people a 
wrong association of ideas, which interferes with the blistering of the head 
in any stage of the fever. Having seen death follow soon after the applica- 
tion of such a blister, they have been led to ascribe the fatal termination to 
the remedy, which, employed at an earlier period, might have prevented it; 
but which, resorted to in the advanced stage, did neither good nor harm. 
When the inflammation is seated in the viscera of the chest or abdomen, 
the blister should be applied to the parietes which are nearest to the affected 
organs, and the larger its size the better. 

The practice of dressing the blistered surface with irritating ointments, 
so as to excite ulcerative inflammation, is not proper. A warm emollient 



532 THE PRINCIPAL DISEASES OF THE 

poultice over the unremoved cuticle is far better, and should be continued 
until a new cuticle is formed, or for several days, when, if found to inter- 
fere with that reproduction, the surface may be covered with collodion, and 
lint or batted cotton applied after the collodion has dried. Under such 
dressings the nervous system will be less disturbed, and the amount of 
revulsion much greater than when unguents of an irritating quality are 
applied. If, however, as sometimes happens, effusion should occur without 
any sustained hypersemia of the surface, which may look white, the addition 
of honey to a hot poultice will speedily bring about a proper action in the 
capillary vessels. 

Sinapisms, often beneficial in the advanced stages, are not equal to blis- 
ters in the early, and should not be employed except to the soles, when the 
feet, in affections of the brain, continue to become cold. 

XIII. Conclusion. — We have now travelled over the treatment appro- 
priate to the early stadia of the typhous fevers. Of course every suggested, 
or even every employed remedy has not been considered ; for, as in the 
treatment of other diseases which refuse to be arrested, a multitude of mea- 
sures have been invented or employed. Yet the means on which the 
physicians of this, and, perhaps, most other countries have placed the 
greatest reliance, have been set forth, and my own humble judgment of 
their modus operandi and comparative value honestly expressed. No one 
will suppose that the whole are to be employed in any single case ; nor, still 
less, that any case is to be intrusted to the efficacy of a single remedy. For 
every patient the physician must make his selections, and from day to day 
his new combinations, according to the general indications, and the seat of 
the varying local affections. 

There are but few diseases the cure of which can be confided to a single 
remedy. Goitre, scrofula, scurvy, and syphilis, are the best examples of 
this kind; but even these often require auxiliaries, in addition to their re- 
spective remedies ; our periodical fevers cannot be met with quinine alone, 
and the phlegmasia, still simpler in pathological elements, require concert 
of remedial action. The plan adopted by the celebrated Louis, and other 
distinguished Parisian physicians, of trying the effects of different remedies, 
apart from others, in the treatment of complex pathological conditions, 
seems to be as unphilosophical as it has proved unsuccessful ; it does not 
even do justice to the single remedy, for while it might, if employed at the 
proper time, in a system of measures, accomplish an important end, it is 
as likely to prove powerless without their assistance. I am obliged, there- 
fore, to reject the conclusions drawn from such modes of estimating the 
value of different remedial agents in the fevers we are now studying. The 
lancet, cups, a blister, an emetic, calomel, a cathartic, a sudorific, laudanum, 
and cold water, might each fulfil some obvious indication in such a fever, 
and be in reference to that the very best, while the preservation of the life 
of the patient resulted from the concurrent action of the whole. In such a 



INTERIOR VALLEY OF NORTH AMERICA. 533 

case the data for an estimate of their relative value is to be found in the 
comparative gravity and importance of the indications under which they 
were prescribed — the ends which they respectively accomplish. 

The author was once told by a young physician, after his return from 
Paris, that one of the most valuable truths he had learned while there, was, 
that if we would know the effects of any medicine, no other must be given 
at the same time. One cannot but regret that he should have been obliged 
to cross the ocean for such an acquisition, and return without learning that 
our remedies in most diseases prepare the way for, or restrain the action of 
each other ; and that an estimate of the effects of the whole is far more 
important than of either considered individually. 

In connection with these remarks, I shall venture to express the opinion 
that an inordinate importance has been attached to what is called the nume- 
rical method, as illustrated in the elaborate work on typhoid fever, by the 
distinguished clinical observer and pathologist just quoted. In the first 
place, although a practicable method in hospitals, superintended by resident 
graduates, capable of observing the rise and decline of every symptom, and 
the precise effect of every prescription, in the absence of the principal 
physician, it is a method which never can be extensively or accurately 
carried out in private practice. Secondly, no two typhous epidemics present 
the same collocation of symptoms and lesions, although their diatheses and 
required constitutional treatment may be nearly or quite identical; and, 
therefore, we can never arrive at a final conclusion as to the order or com- 
parative frequency of different local affections. Thirdly, nor is this neces- 
sary • for if we know that the brain, the lungs, the spleen, the stomach, the 
liver, the ileum, are liable to be implicated, and are thereby instructed to 
watch them vigilantly, it can be of no practical value to know precisely 
their relative frequency ; as, for example, that in a given number of cases, 
one-half will present an affection of the lungs, and one-third an affection of 
the brain. A knowledge of their comparative liability will not establish 
the existence of either in any particular case. Fourthly, the symptoms and 
lesions are modified by the treatment. Some are mitigated or removed; 
others may be aggravated or prolonged ; and hence two cases, which, left to 
themselves, might have presented the same concourse of symptoms and the 
same lesions after death, may, under the influence of different modes of 
treatment, show many divergencies in their progress. Fifthly, the numerical 
method, followed for an indefinite length of time, does not give us a final 
and reliable conclusion ; for all the cases of the disease to which it is ap- 
plied, that ever have occurred and ever will occur, belong to the data 
necessary to such a deduction, which, being thus made, would express with 
mathematical accuracy a certain portion of its history, though it might give 
us no more assistance in the treatment than an approximative estimate. 

Thus I cannot concede that observations' not made on the numerical 
method are of no practical value. On the contrary, I attach importance to 



534 THE PRINCIPAL DISEASES OF THE 

the conclusioDs, at which acute and observing men have arrived, under 
the daily and reiterated impressions made on their minds in the practice of 
their profession. Our diagnosis and therapeutics have been constructed of 
materials thus collected ; and will continue to be improved and perfected 
in the same manner. The numerical method may throw its exacter con- 
tributions into the great volume of data, but will never exclude those col- 
lected in a different mode. 



SECTION y. 

TREATMENT OF THE MORE ADVANCED AND FINAL STAGES OF THE 
TYPHOUS FEVERS. 

I. No line of demarcation can be drawn between the stage through which 
we have passed, and that on which we are now entering ; for no sudden 
change in the phenomena, like those which characterize the successive 
stages of small-pox, occur in these fevers. Yet in their progress some of 
the earlier disappear or are greatly modified, and new ones progressively 
arise which continue to the end. Hence if we compare two cases in the 
earlier or the later periods, they may resemble each other closely ; but the 
different stages do not. As to the time of culmination or change, nothing 
can be more indefinite ; for in some cases, the primary symptoms degene- 
rate into or are blended with the supervening symptoms of the final stage 
within a few days, in other cases not till a far longer time has elapsed. 
But what are the symptoms which characterize the earlier and later stadia 
of these fevers ? I may say in general terms that a white tongue, sustained 
and general heat of the surface, a bounding and sometimes firm pulse, with 
pains more or less acute, and a comparatively active state of the intellect 
and senses, may be taken as characteristic of the earlier stages ; while a 
change in the tongue to a dry and dark surface, a failure in the energy, 
with increased frequency, of the pulse, a depressed state of the mental 
faculties, blunted sensibility, drowsiness, subsultus tendinum, and depraved 
secretions express the more advanced periods; the transition being in some 
cases rather sudden, but in general so gradual that no actual beginning is 
observed. 

Now the treatment which has been laid down is applicable to the former 
period, but not to it only; for much of it applies to the latter, in which 
some things may be done with more, others with less energy, than in the 
earlier periods. 

II. As a general fact, the progress of the fever demands a more limited 
employment of whatever enfeebles the system. Hence, venesection is no 
longer admissible except, perhaps, in an occasional case of acute cerebral 
or pulmonary inflammation, when the typhous diathesis is not highly deve- 
loped. Topical bleeding, however, is still not only admissible, but often 



INTERIOR VALLEY OF NORTH AMERICA. 535 

indispensable, for the subdual of inflammation in the organs just mentioned, 
in the mucous membrane of the stomach, the glands of the ileum, the liver, 
and doubtless in the spleen. The degree to which it may be carried, must 
be decided in every case by the intensity of the symptoms and its effect on 
the strength of the patient. The length of time after the commencement 
of the reaction beyond which local bleeding is inadmissible, cannot be de- 
termined, for according to the rapidity of the disease it may be only a few 
days or as many weeks. The strength of the heart, of the muscles of loco- 
motion, are exponent of the energy of the brain ; and the presence or ab- 
sence of a petechial or hemorrhagic tendency, must guide us in this de- 
cision. When the exhaustion has reached a certain point, which must be 
judged of by the physician, local bleeding is no longer admissible, what- 
ever may seem to be the state of the suffering organ ; and yet this rule 
cannot be taken in the absolute, for we must exclude from it certain cases 
of short standing, in which the failure of strength results in part at least 
from the engorgement of the brain or lungs. 

III. Vomiting may sometimes be serviceable in this stage, even to a late 
period ; but tartarized antimony is longer admissible, and the best formula 
is a salted infusion of mustard, administered in such quantities as to operate 
promptly, and not debilitate by protracted nausea. I shall not repeat what 
has been already said on the modus agendi of this class of medicines; but 
add, that an important benefit from vomiting in this stage of the fever, is 
the increased perceptibility of the stomach to the impress of food and tonics 
and stimulants, now become an important part of the treatment. The 
stomach is one of the four great organs which in different ways influence 
the whole. The brain elaborates and sends through the organism its pecu- 
liar influence ; the lungs rid the blood of its superabundant carbon and im- 
bue it with oxygen j the heart keeps it in circulation ; one mission of the 
stomach is to radiate excitement, raised in itself by the action of external 
agents received into it. To whatever extent they may be absorbed and 
brought to act on the internal surface of the arteries, there is I think 
abundant evidence that they make a primary, and according to the dose and 
nature, powerful impress on the stomach, which through the nerves is trans- 
mitted to the heart and brain. If the agents be healthy excitants or stimuli, 
those organs are normally excited, and performing their functions with in- 
creased activity, the whole organism is raised into higher excitement. Such 
being one of the great offices of the stomach, which it performs in virtue of 
its sensibility and contractility, we may be sure that when they fail in the 
progress of a typhous fever, the means which experience has shown to be 
necessary to the maintainance of the strength and activity of all the organs, 
will fall short of the full effect — and may, indeed, be administered without 
any beneficial result. Thus it is that we find one reason for occasional 
vomiting, even when the fever is far advanced. But there is still another. 
The lungs in that stage are sometimes deeply engorged, and local bleeding 



536 THE PRINCIPAL DISEASES OF THE 

is no longer effective ; but free vomiting often gives great relief. The ca- 
pillary system is quickened into contraction, and empties itself. This mode 
of relief must not be confounded with that in pneumonia, from the liberal 
administration of the great contra-stimulant, tartar emetic, which would 
now be too debilitating. 

IY. Purging, which in the beginning must not be carried very far, in the 
latter period of the disease, can never be excited without danger. Consti- 
pation is then auspicious, unless there should be inflammation of the brain; 
yet it should not be allowed to continue indefinitely. It may in general be 
obviated by stimulating enemata, such, for example, as watery infusion of 
assafcetida, with oil of turpentine, and sugar or honey. Of aperients by the 
mouth, the following pill is one of the best : — 

R. — Blue Mass, Rhubarb, Assafcetida, and Extract of Hyoscyamus, of each, 
equal parts, beat into a mass -with rectified Oil of Amber. One or two four-grain 
pills will generally be sufficient. 

Another laxative appropriate to this stage, is the tincture of rhubarb and 
gentian, of our pharmacopoeias, administered in drachm or two-drachm 
doses. 

Whatever is administered, should have its operation restrained within 
moderate limits by the use of laudanum ; and when the strength of the pa- 
tient is greatly reduced, he should be required to use the bed-pan. Calomel, 
in minute doses, may be substituted for the blue pill, but should not be 
often repeated, and never administered, as in the earlier stages, for the pur- 
pose of exciting salivation. 

Y. In the latter stages of the fever, the physician should still endeavor to 
bring on perspiration, but must employ only the most stimulating sudorifics. 
The antimonials are no longer admissible, except in minute doses, combined 
with excitants, and then they should be limited to cases unaccompanied with 
diarrhoea. The infusion of serpentaria or eupatorium is now valuable. The 
spiritus Mindereri with an excess of the carbonate of ammonia, may be made 
the vehicle of other diaphoretics, as the wine of ipecacuanha and paregoric, or 
one of the preparations of morphia. Pills of equal parts of Dover's powder and 
camphor, in connection with hot wine whey often afford satisfactory results. 
Should no diaphoresis ensue, but the pulse become more frequent and the heat 
of the surface increase, pellets of ice, or draughts of cold water, which before 
such medicines had been administered, would have been too refrigerating, 
may now prove refreshing and bring on a sweat. In such cases attention must 
be given to the heat of the lower extremities, as the skin is one organ, and 
if a portion of it be cold, the remainder can with difficulty be brought into 
perspiratory action. 

YI. Water is still of use, therapeutically, in the more advanced stages 
of the fever. As long as reaction will follow on the sudden affusion of that 
which is decidedly cold ; it may be advantageously applied as a general in- 



INTERIOR VALLEY OF NORTH AMERICA. 537 

direct stimulus, but the physician should superintend its application. In 
this stage, when there is much heat of skin, it may be moderated by spong- 
ings with subtepid vinegar and water, which the patient always finds refresh- 
ing. When the heat of the head is inordinate it may be reduced by cold 
or subtepid applications, but I doubt the propriety of applying ice in this 
period of the fever. It should not be forgotten, that one means of cooling 
the head is to warm the feet. It is common to ascribe the heat of the head, 
in this stage, to inflammation, and say that the patient dies of that local 
affection, and this is doubtless true in many cases; but from the absence of 
the traces of inflammation of the brain, in so large a number of autopsies, 
we may take another view, and conjecture that the preternatural heat 
of the head in the declining stage of these fevers may sometimes be an 
example of what is denominated the vis medicatrix. The vital energies 
concentrate themselves in the brain, as the troops of a besieged fortress 
collect in its citadel when they have become too few to man and defend the 
dilapidated outworks. According to this hypothesis it is possible that the 
life of the patient is sometimes prolonged by the very condition which we 
regard as the chief cause of his death. If I am not mistaken, we see this 
illustrated in death from starvation. Dissection has often revealed in such 
cases, congestions of the brain and stomach. Now the former develops and 
sends throughout the organism, a sustaining influence (I can use no more 
definite expression), and the latter, as we have seen, is an organ which 
sympathetically excites the rest. Thus physiology suggests that if our 
organism be endowed with a principle of self-preservation, the capillary ex- 
citement will, under starvation, make its last rally in the two organs just 
named. The practical deduction from this speculation is, that we may some- 
times injure our patients in the closing stage of typhous fever, by over- 
officious refrigeration of the head. 

It is a curious fact, that the negro, who is intolerant of cold, has an 
instinct which leads him to protect his head, rather than his feet. It is 
well known in the northern slave-holding states, that in cold nights he is 
prone to sleep with the crown of his head near to the fire, and his feet ex- 
posed, on his own theory that the head must be kept warm. With this 
practice, and the assigned reason, the author was familiar, before visiting 
Quebec, in 1847, but while there, he met with Dr. John Campbell, of the 
British Army, who gave him the following. During the siege of New 
Orleans, in December, 1814, while a black regiment, from the West Indies, 
was encamped below the city, the cold was such, that the thermometer 
sunk to 24°, when the toes of a large number, defended by shoes without 
stockings, were frost-bitten. Thereupon Dr. Campbell ordered an issue of 
woollen socks, which, however, they drew on their heads instead of their feet, 
saying that " if the head was kept warm, all the rest of the body would be." 
The suggestions of this instinct of the African race, should not be disre- 
garded. The bountiful covering of hair, a very imperfect conductor of 



538 THE PRINCIPAL DISEASES OF THE 

caloric, with which the head is supplied, coincides with the African philo- 
sophy, and our own habits in winter, go to strengthen the same conclusion, 
for the individual may have his feet frostbitten, without any great or imme- 
diate enfeeblement or failure, but he suffers severely, if he allow his head 
to become chilled. A high and sustained temperature of the brain seems, 
indeed, to be indispensable to its successful working. 

VII. In the latter stadia of the fever, blisters should be used with great 
reserve, as the denuded surfaces are prone to gangrene ; and though this 
may not occasion the death of the patient, his friends are not likely to take 
that view of the matter. For the relief of local affections, and as general 
stimulants, rubefacients, cataplasms, and lotions, which do not detach the 
cuticle, and produce a deeper and more sustained hypercemia, are greatly to 
be preferred. The most convenient and efficacious articles are mustard, 
capsicum, oil of turpentine, and ammonia, the last in the form of Gran- 
ville's lotion, or the compound liniment of the pharmacopoeia. The first is 
the most enduring, the last most speedy and transient in its effects, and 
therefore adapted chiefly to sudden failures of the vital energy. The in- 
sensibility of the patient will in many cases prevent his complaining of the 
sinapism, but that should not lead to its being kept on the same place for 
more than a single hour, for if kept longer, gangrene may follow. To be 
effective, turpentine should be applied warm, and if saturated with camphor, 
its effects will be still better. 

VIII. The vegetable acids, so beneficial, or at least acceptable, in the more 
acute stages of the fever, are now too refrigerant and sedative; but the 
mineral are not liable to that objection, as experience has placed them in 
the class of tonics. Which of the four — sulphuric, muriatic, nitric, or 
phosphoric — should be preferred, cannot in the present state of our know- 
ledge be decided. These acids quench thirst, and seem therefore to have 
an anti-febrile power; at the same time they exert a tonic influence by 
which they may favor the restoration of appetite, and perhaps improve the 
vital cohesion of the capillaries, thereby contributing to the prevention of 
hemorrhage. Of their effects on the blood it is impossible to speak either 
definitely or definitively, but from the analogies between the state of that 
fluid in scurvy and in the latter periods of many cases of typhous fever, 
we may, perhaps, assume, that a part of the benefit which they afford, is 
directly due to their influence on that fluid. 

To give energy to the stomach and restore the appetite, the sulphuric, in 
the form of elixir of vitriol, is perhaps preferable. It is, I think, the best 
tonic of the whole. When it disturbs the bowels, the addition of an equal 
or greater quantity of paregoric -will, generally, restrain it. 

Should there be much hepatic derangement, the nitric acid should receive a 
preference, from its action on the liver. It has been proposed, however, to 
use this acid for the purpose of controlling the fever, in cases not attended 
with hepatic disorder. 



INTERIOR VALLEY OF NORTH AMERICA. 539 

As neither sulphate nor nitrate exist in the blood, while the muriate of 
soda and potash constitute its most important saline elements, we are at 
liberty to suppose that muriatic acid finds a readier admission into the blood- 
vessels than either of the others, and is more likely to exert an influence on 
that fluid than they. We know not how it may act, but if there be any 
reality in the old opinion of an incipient putrefactive decomposition of that 
fluid in certain cases of typhus, there may be a development of ammonia, 
to a neutralization of which the acid would be fitly adapted. We know 
that in the advanced stages of typhus, the blood coagulates very imperfectly, 
and it may be from its correcting that diseased condition that the muriatic 
acid is a good anti-heniorrhagic in those fevers. Whatever be its mode of 
operation, I have found it beneficial. 

Phosphoric acid has not, I think, been used in this country. It has been 
employed in G-ermany and regarded as a general tonic and mild stimulant. 
Its presence in the blood and the presence of phosphorus in the healthy 
brain, which is greatest duriDg the most active era in the existence of that 
organ, would seem to warrant the expectation that this acid would be found 
useful in the weak and degraded condition of the nervous system which so 
eminently characterizes the latter stages of typhus. 

Astringents. — Two pathological events demand the use of astringents, — 
diarrhoea and hemorrhage. 

A. The diarrhoea in continued fever may depend on one or more of the 
three following pathological conditions : morbid secretions reacting on the 
bowels, morbid contractility, and inflammation or ulceration of the glands 
of the ileum. When the conditions producing it are removed, it of course 
ceases, but such a cure is not often practicable, for those conditions being 
parts of the general pathological state which constitutes the fever, may be 
intractable — meanwhile the continued excretion may rapidly exhaust the 
patient, and signally interfere with the effects of medicines given to act on 
the skin, lungs, or kidneys, and should therefore be checked. Various 
means of restraint have been already referred to, but I must here add a 
paragraph on astringents proper. 

1. Tannin, or more correctly tannic acid, may be regarded as the vegetable 
astringent. Separated from every other element of the astringent plants, it is 
one of the most convenient and powerful of our means for restraining diar- 
rhoea. When much fever is present, it may be combined with ipecac* in 
the proportion of four grains to one ; or with Dover's powder in equal pro- 
portions. Thus while the secretions and excretions from the mucous mem- 
brane are restrained, those of the skin will be promoted. It may, also, be 
given in pills with blue mass and opium, in the proportion of three grains 
of the first, one of the second, and a fourth of a grain of the third. It 

* [Ipecacuanha is incompatible with any vegetable astringent containing tannic acid, which is its 
natural antidote. — Ed.] 



540 THE PRINCIPAL DISEASES OF THE 

may likewise be administered in the liquid form, of which the tincture of 
galls is a good preparation. 

2. Kino, one of the astringents which I have oftenest employed, and 
which is I think in most general use, may be administered in pills with 
opium, in the proportion of five grains to one-fourth of a grain ; but its 
officinal tincture is more generally used with the chalk mixture, in the pro- 
portion of a drachm to the ounce, with or without laudanum. 

3. It would be waste of time to name all the vegetable astringents, but 
I must not pass over our indigenous Geranium maculatum, or crow-foot. 
I have been long accustomed to employ the root of this plant boiled in 
sweet milk and strained. A strong decoction of this kind is a powerful 
astringent, which lies well on the stomach, and soothes while it restrains 
the action of the bowels. An ounce is the proper dose, frequently repeated. 

4. Of mineral astringents, the carbonate of lime, and lime itself, although 
not potent, are in general and perhaps deserved use. The hydrargyrum 
cum creta, not limited to cases accompanied by diarrhoea, is almost inva- 
riably employed by our physicians, when they suspect an affection of the 
Peyerian glands. In large doses it may act on the bowels, in virtue of the 
mercury, which although but mechanically divided in the mixture, is 
brought into a condition to absorb oxygen, and become a protoxide in the 
bowels. Hence the union of Dover's powder on small doses of opium, is 
often required. The chalk mixture already mentioned, is also a favorite 
prescription, but is generally given in doses too small. It is a good vehicle 
for the vegetable astringents, and the tincture of opium. Lime water is 
often beneficial, and may be given alone or in combination with boiled milk 
or an infusion of the bark. All the cretaceous preparations are especially 
proper when the excretions are acid. 

5. Of metallic astringents one of the most convenient and reliable is 
the acetate of lead. When there is much fever, with evidences of intesti- 
nal inflammation, its solution in vinegar should be preferred. One scruple 
to the ounce is a good proportion, the dose of which may be a teaspoonful. 
It is, however, more commonly given in substance, alone or combined with 
ipecac, or opium or both. The dose may then be from two to five grains. 
In giving this easily decomposed medicine we should withhold the chalk 
and lime water, the sulphates, muriates, and even draughts of hard water, 
as incompatible. 

B. Hemorrhages in the early stage of typhous fever, generally from the 
nose, seem to depend entirely on congestion — in the advanced stages on con- 
gestion, diminished vital cohesion, and liquefaction of the blood. The acidu- 
lated astringents are most successful in their arrest. Thus tannin may be 
administered in claret, as pointed out in treating of yellow fever ; the acid 
solution of sugar of lead is preferable to that salt in substance ; the aromatic 
sulphuric acid with double its quantity of paregoric, in 30-drop doses, is now 
valuable ; and the acid sulphate of alumen and potash or common alum, 



INTERIOR VALLEY OF NORTH AMERICA. 541 

may be administered with much confidence ; but the salt of lead must not 
be administered at the same time with the two latter prescriptions ; nor the 
alum at the same time with the tannic acid. Alum may be administered 
in powder with an equal quantity of white sugar, with every scruple dose 
of which a quarter or half a grain of finely powdered opium, or an eighth 
of a grain of sulphate of morphia may be advantageously mixed. 

To these active agents I must add creasote, which I have not myself em- 
ployed in the cases under consideration, but am assured by Dr. Sowell of 
Alabama,* that he has employed it with very great success. 

The agents we have reviewed should not be restricted to cases of actual 
hemorrhage; but given freely whenever extensive petechiae or vibices, dis- 
close the existence of a hemorrhagic diathesis. 

IX. The vegetable tonics have long been standing remedies in the declin- 
ing stages of the typhous fevers. It may be doubted whether the good 
they have done has contributed more to their continued use than the in- 
stinct or feeling which prompts us to administer stengtheners, when we see 
the strength of a patient wasting away. All the officinal bitter tonics have 
been prescribed in cases of this kind. They are good vechicles for the 
mineral acids. 

It is often useful to add some aromatic stimulant, such as cardamom. 
The infusion of gentian and orange is a simple bitter which generally lies 
well on the stomach. When diarrhoea, with lesion of the glands of the 
ileum, prevails, the cold infusion of wild cherry bark (Prunus Virginiana), 
made by displacement, is appropriate, and under the same pathological cir- 
cumstance, the infusion of calumbo root, prepared in the same manner, is 
still more valuable, from the presence of gum and starch. 

Early in the present century an opinion spread over the West that' 
the root of the Frasera Walteri, a stately and beautiful plant of the wood- 
lands and prairies, was the identical " calumbo" of the shops ; and it was 
immediately made to some extent an article of commerce. As the plant 
furnishing the officinal root was not then known, the identity or diversity 
could only be determined by a pharmaceutical examination. This led the 
author, in 1809, to institute a series of comparative experiments, that 
proved them to be from different plants, which the researches of the bota- 
nists have since confirmed. The results of this examination were published 
the next year ;j" but that which began as an honest, though hasty conclu- 
sion, was continued as a fraud, and there can be little doubt that much of 
the officinal calumbo, for a long time after, if not down to the present time, 
has been adulterated with the Frasera. This adulteration, according to 
Pereira, even made its way to France. The Frasera root is a good bitter 
tonic, but has never been extensively used by our physicians. 

To enumerate all the vegetable tonics which have been employed in 
typhous fever would be a waste of time, and I shall conclude with a refe- 

* Letter of August 1st, 1851. t Notices Concerning Cincinnati, 1810, p. 61. 



542 THE PRINCIPAL DISEASES OP THE 

rence to the bark and its preparations. Before the discovery which re- 
sulted in the preparation of the salts of quinine, the bark was very gene- 
rally employed in our typhous fevers, as it was in Europe. Its control over 
the periodical, suggested, perhaps, that it would be efficient in the continued 
fevers. In former times, I gave it a thorough trial, but with no other 
result than the conclusion of its being the best of our vegetable tonics. 
It does not seem to possess the power of shortening those fevers in the 
latter stages, as we have seen the sulphate of quinine does not of arresting 
them in the former. Its greatest power is manifest when it is made into 
an electuary with camphor and finely powdered opium, the tincture of cin- 
namon, or some other aromatic being used to form the pultaceous mass. 
It is, however, more commonly given in the form of infusion, or decoction, 
with serpentaria. When diarrhoea is present, such a preparation may be 
advantageously combined with an equal quantity of lime-water. I have 
also employed the compound, or Huxham tincture, and in cases which 
demand a stimulant it may be preferred. 

Of the sulphate of quinine I have already spoken. In the latter stages, 
when an efficient tonic is required, it is less reliable than the bark ; but 
being more acceptable to the stomach in certain cases, may, in such, be pre- 
ferred. Small doses, as, for example, a grain, or at most two grains, every 
two hours, will be best. It may be given with elixir of vitriol in acid solu- 
tion, to which a minute quantity of sulphate of morphine may be added, 
or in the form of pills, combined with camphor and opium. To such a 
compound, the addition of ipecacuanha, in subnauseating doses, will some- 
times impart a diaphoretic property, and procure rest with gentle per- 
spiration. 

It seems almost unnecessary to add that if a decided inflammation of any 
organ should exist, however advanced the stage of the fever, or great the 
debility of the patient, the vegetable tonics are contraindicated. 



SECTION VI. 

TREATMENT IN THE PINAL STAGES CONTINUED. 

It would be tiresome even to call over the catalogue of local, diffusible, 
narcotic, and antispasmodic stimulants, derived from all the kingdoms of 
nature, which have been administered in the declining or closing stages of 
continued fever. Their great number may well raise a suspicion of their 
efficacy. That they have often done harm by being administered when 
inflammation, especially of the brain, was present, cannot be doubted, and 
hence the deep importance of the symptoms by which inflammation may be 
distinguished from irritation and exhaustion. After commencing their 
administration, however, we may generally judge of its propriety by their 



INTERIOR VALLEY OF NORTH AMERICA. 543 

effect on the circulation. If they were truly indicated, the pulse will be- 
come slower and fuller ; if it should become more frequent, they should be 
discontinued. Again, they have done harm by being exhibited in excessive 
quantities ; and, on the other hand, they have failed from a timid adminis- 
tration. Still further, their benefits have sometimes been diminished by 
using a single one too long; for while the effects of some medicines, as tar- 
tarized antimony, digitalis, arsenic, and calomel, are cumulative, that is, 
they produce a state of the system which gives to the subsequent greater 
efficiency than the former doses, the medicines we are now studying lose 
their power by repetition, which renders augmented doses, or a change of 
articles necessary. In enumerating the principal stimulants, I will begin 
with one which is, perhaps, much more local than general, and would pro- 
bably have been as much in place, when treating on the cure of the first 
stages of the fever, as here. 

1. The tincture of cantharides has been employed in a typhous fever of 
Mississippi with success. Dr. Robert E. Lanier, of Columbus, in that 
state,* informs me that he has used it for several years, with a success that 
has given him great confidence in its efficacy. He administers it in every 
stage of the disease. His dose is five drops of the officinal tincture every 
five hours, suspending it on the occurrence, and during the continuance of 
strangury. It frequently operates as a diuretic. It has never failed to 
remove the dryness and otherwise improve the appearance of the tongue. 
The fever gradually abates under its use. 

Cantharides is more of a local than a general stimulant. It acts espe- 
cially on the mucous membranes of the digestive and urinary passages, and 
is capable of making a powerful stimulant or phlogistic impression on those 
surfaces without much exciting the heart. In large doses, however, its 
action reaches the brain, producing coma. I can see no reason, a priori, 
why such an agent might not prove a valuable alterant or counter-irritant 
in typhous fevers. 

2. Oil of turpentine, which, in its action on the skin and mucous mem- 
branes, somewhat resembles cantharides, has long been employed in typhous 
fevers, and its use in the Interior "Valley is universal — not in every case, 
but in every part of the country. It is regarded as exerting its influence 
chiefly on the alimentary membrane, superseding incipient inflammation, 
arresting the, progress of glandular lesions in the ileum, promoting the 
action of the bowels, when aperients are necessary, without occasioning 
hypercatharsis or increased debility, and, above all, exciting those peri- 
staltic actions which effect the expulsion of flatus, and avert or remove 
tympanitis. It has also been found beneficial in hemorrhage from the 
bowels. It excites the pulse more than the tincture of cantharides, but 
can scarcely be ranked with the stronger constitutional stimulants. Its 
absorption, an admitted fact, and its action on the kidneys, skin, and lungs, 

* Letter dated May 5th, 1851. 



544 THE PRINCIPAL DISEASES OF THE 

as a stimulating secernent, suggest that it may confer benefits in the fevers 
we are now considering in other modes than by impressing the mucous 
membrane of the stomach and bowels, and as in large doses it is capable of 
changing the condition of the nervous centres, a part of its good effects may 
perhaps result from its alterant influence on the morbid innervation. On 
the whole, it may be regarded as one of our valuable therapeutic agents in 
the advanced stages of abdominal typhus. It may be administered in doses 
of twenty, forty, or sixty drops, every two or four hours, in a spoonful of 
wine, or absorbed by finely pulverized sugar. 

3. Tincture of Gruaiacum. I am not aware that this medicine has been 
used in the latter stages of typhous fevers, but am disposed to invite atten- 
tion to it. More exciting to the circulation than turpentine, it has with 
that medicine some pharmaceutic and therapeutic relations. Its direct in- 
fluence on the mucous membrane, its known efficacy as an alterant, and its 
action under some circumstances as a diuretic, but, more generally, a dia- 
phoretic of sustained power, seems to suggest that when we would support 
the energies of the heart and brain, and at the same time act on the capil- 
lary system, secernent and non-secernent, this medicine might be advan- 
tageously given. The medium dose might be twenty drops every two hours, 
in wine or milk ; and when diarrhoea is present, the latter should be boiled. 

4. Camphor excites the heart and the organs of secretion less than 
guaiacum, but acts with greater energy on the nervous system, in which it 
raises a temporary excitement, without implicating the organs of circula- 
tion to any great extent. In a morbid frequency of the pulse not depend- 
ing on inflammation, a diminution may take place during its employment, 
apparently from a diminution of the contractility of the heart. The long 
sustained use of camphor in the typhous fevers must be received as con- 
clusive proof of its utility. Its benefits seem to be conferred on the ner- 
vous system, and are most obvious in sudden failures of the nervous func- 
tion in the latter stages of the fever. Most of our physicians testify to its 
power in similar cases, though few of them give it in the doses recommended 
by our Canadian brethren in imitation of Hildenbrand. In the administra- 
tion of any nervine in the typhous fevers, it is advantageous to determine 
its action on some secretory organ. To this end nitrate of potash and sugar 
may be triturated with camphor previously moistened with alcohol, and 
administered in the form of powder ', or it may be given in suspension ac- 
cording to the following formula : — 

R. — Camphor moistened -with alcohol, gj. 
Gum Arabic, gij. 

Triturate together and add, gradually, 
Water, ^vii. 
Spirit of nitrous ether, ^j. 

Half an ounce may be administered, after agitating the vial, every two 
hours or oftener. 



INTERIOR VALLEY OF NORTH AMERICA. 545 

These additions will determine the action of the medicine upon the kid- 
neys. But an action on the skin is more important than on the kidneys, 
and to this end Dover's powder may be substituted for the nitre, in half 
the quantity of the camphor ; the wine of ipecac, and paregoric, in equal 
quantities, may replace the spirit of nitre in the second recipe. In low de- 
lirium, without cerebral inflammation, in subsultus tendinum, and hiccough, 
and other forms of muscular debility and spasm, camphor manifests its 
greatest power. If, however, I were to rely on my own experience, I would 
say that the beneficial effects of camphor in the typhous fever have been 
overrated, or at least that its effects have been very unequal in cases appa- 
rently the same. 

5. Valerian has been used in the latter stages of typhus, but it is un- 
certain and variable in its effects. Its infusion, prepared by displacement, 
may, however, be substituted for water in the camphor mixture just de- 
scribed. 

6. Sulphuric ether, is certainly a nervine of considerable power j but its 
temporary effect, and the difficulty of administering it to typhous patients 
in the latter stage of the fever, are objections to its use. 

7. In former times, I was accustomed to prescribe musk, as a nervine 
and antispasmodic for the correction of certain symptoms in the advanced 
stages of the typhous fevers, but found the results of its administration too 
variable to justify the practice. In many cases it was no doubt adultera- 
ted ; and when genuine its price is too high for general practice. 

8. Assafoetida I regard as superior to musk as a sustainer of the nervous 
system of animal life, and a quieter of the ataxic and spasmodic movements 
of the muscular. Its effects, moreover, are not confined to the cerebro- 
spinal nerves, for it allays spasmodic action and promotes the expulsion of 
flatus from the alimentary canal; excites the heart, and combined with 
other agents, may determine its action on the secretory apparatus of the 
skin and lungs. As an antispasmodic in the typhous fevers, its powers 
exceed those of opium while its narcotic properties are very feeble. It 
may, therefore, be administered in states of the brain which contraindicate 
the use of that soporific. When such contraindication does not exist, opium 
may be combined with it, in the proportion of one-fourth of a grain to four 
or five grains of assafoetida, and administered every two or four hours, with 
much advantage. An equal quantity of camphor added to the formula, 
and the whole made into a soft bolus, will, perhaps, give as genial a sup- 
port to the innervation, in the absence of cerebritis, as any agents known 
to us. 

In the diarrhoea of the latter stages, thick injections of starch, prepared 
with a strong watery infusion of assafoetida and opium, instead of water, 
are beneficial. 

9. Ammonia and its sesqui- or subcarbonate, especially the latter, are in 
general use throughout our Valley in the advanced stages of typhus. They 

vol. ii. 35 



546 THE PRINCIPAL DISEASES OF THE 

are both local and general stimulants, but their effects on the organism at 
large are much more transient than upon the surface to which they are ap- 
plied, and which they can speedily irritate into inflammation. The car- 
bonate is generally employed. It is frequently administered to relieve 
a suddenly developed subsultus tendinum; but more commonly to arrest 
the sinking energies of the heart and capillaries, especially those of the 
skin and lungs, and hence it is common to give hot wine whey at the same 
time. As the milk employed for this purpose is sometimes sour, and all 
our wines are acid, the probability is, that in many cases much of the car- 
bonate is decomposed, forming the lactate, acetate, tartrate, or malate of 
ammonia, or several of them. This, however, can do no harm, provided 
the carbonate be administered in liberal quantities ; on the contrary those 
salts, readily taken into the circulation, probably excite the action of the 
secretory organs, and thus enlarge the sphere of benefits. This perhaps is 
the true reason why wine whey rather than any diaphoretic infusion has 
become associated with the carbonate of ammonia in our prescriptions. If 
gastritis or cerebritis be present, the carbonate of ammonia is contraindi- 
cated. Experience has shown, however, that in the pneumonia of these 
fevers it maybe administered freely, and often contributes to the resolution 
of the inflammation, and causes increased secretion from the bronchial 
membrane. Thus it comes to the relief of the patient, when from his de- 
bility and low degree of inflammatory action, with suffocation, tartarized 
antimony and cupping would be injurious, and blistering ineffective. 

Hemorrhagic tendency, with that dissolved and deteriorated blood which 
we know to be a reality, and to which our predecessors applied the epithet 
putrescent, contraindicates a large and continued use of the carbonate of 
ammonia, as that medicine, not less than the fixed alkalies, tends to the pro- 
duction of such a state, with softening of the solid tissues, thus increasing 
the danger of hemorrhage. Moreover, if there be a reality in the old 
speculation of putrescency, one of the first effects of sanguineous decompo- 
sition may be the development of ammonia in the blood. 

Our prescriptions are sometimes so managed, that much of what is taken 
by the patient has, by the escape of ammonia, been brought to the condition 
of neutral carbonate or bicarbonate, when, as a stimulant, its activity is 
greatly reduced. In cases, then, which are trusted to the exciting power 
of this medicine, the prescription should be put up afresh two or three times 
in the twenty-four hours. 

10. Under the head, Mineral Acids, reference was made to the phosphoric 
as a tonic which contained one of the elements of the brain — phosphorus. 
That element belongs to the class of energetic local and general stimulants. 
The physicians of the Interior Valley were first apprised by Dr. Eberle,* 
that phosphorus had been employed in the typhous fevers. All his autho- 
rities were continental, and chiefly German. Nearly thirty years have 

* Treat, on the Mat. Med. 1822. 



INTERIOR VALLEY OF NORTH AMERICA. 547 

elapsed, but I am not aware that it has been administered. I have intro- 
duced it here because organic chemistry has taught us that it is one of the 
elements of the brain and spinal cord, which in manhood is nearly twice 
as great as in infancy, old age, or in the idiotic. It seems, therefore, to be 
necessary to the normal activity of the cerebro-spinal centre so signally 
degraded in the typhous fevers. 

In advanced stages of typhus, unaccompanied by cerebral or gastric 
inflammation, when we see the vital forces, especially those of the brain, 
day after day becoming more exhausted, in despite of all our ordinary tonics 
and stimulants, why should we not give this energetic element of the cere- 
bral mass a full and fair trial ? Our books of Materia Medica, above all, 
the admirable work of Dr. Pereira, give ample instruction as to the prepa- 
ration, management, and use of this comparatively untried excitant, and I 
cannot but hope that those who practise much among our typhous fevers, 
will test its powers by a diversified exhibition. 

11. No medicine of the class we are now considering has been so gene- 
rally administered in the typhous fevers as opium and its preparations. 
We have already seen that it is often combined with other remedies, which 
it either restrains or assists in their operation. Thus, united with tartarized 
antimony, it prevents an action on the bowels, and promotes one on the 
lungs or skin ; and mingled with Spiritus Mindereri, which alone might 
operate as a diuretic, a sudorific effect is produced. Furthermore, it recon- 
ciles the stomach to many medicines which would otherwise irritate it, and, 
as a general fact, does not diminish but increases their specific effects. For 
the morbid sensibility and contractility of the muscles of organic life, it is 
our most reliable resource, often quieting the restless movements of the heart, 
and, above all, of the bowels ) being, in fact, by far the most important 
means which we possess for holding in check the diarrhoea which so often 
rapidly exhausts the patient in the latter stages of typhus. To this end it 
may be combined more or less with all our tonics, astringents, and stimu- 
lants, whether given by the mouth or thrown into the rectum. If our 
blisters produce strangury, its combination with camphor will give early 
relief. When hemorrhage occurs, its liberal administration, with or without 
astringents, is generally beneficial. But, above all, it is adapted to the 
lesion of innervation in the organs of animal life. I do not mean that it 
can establish such an action as will set aside that which I have assumed to 
constitute the first link in the morbid chain, but it unquestionably exerts a 
palliating and sustaining power. From its administration many a patient 
has enjoyed a more comfortable night than if it had been omitted; and 
others have derived manifest benefit from its supporting influence, when 
liberally given in a solid form at regular intervals. This method, long 
known to the profession, but not always recollected, I have certainly found 
advantageous. Inflammation of the abdominal and thoracic organs does 
not, in my opinion, contraindicate the use of opium; that of the brain 
more certainly does. How shall we always decide, however, between in-. 



548 THE PRINCIPAL DISEASES OF THE 

flammation and exhaustion with irritation of that organ. I shall not here 
repeat what has been already said on that subject, but will venture the 
opinion that the latter of those states has been quite as often mistaken for the 
former, and opium withheld when it should have been given, as vice versa. 

When administered as an adjuvant, such preparation of opium as seems 
most convenient may be selected, but for a decided and permanent impres- 
sion on the nervous systems of either organic or animal life, I have found 
solid opium the most effective. In latter times, the salts of morphia have 
been much employed, and they may sometimes assist our diaphoretics more 
efficiently than opium, though, in reference to the general lesion of innerva- 
tion, I have not found them equal to the parent drug. 

12. Alcohol in its various preparations has been at all times employed 
as a stimulant in the declining stages of the typhous fevers. The patho- 
logical conditions which forbid their use are the same as oppose the use of 
opium, camphor, and other excitants. They are even more decidedly contra- 
indicated than those stimuli which exert an influence on the secretions. Ex- 
perience shows that alcoholic liquors are excitors of both the nutritive and 
animal organs. Their effect on the brain is early and decided. It is scarcely 
less so on the spinal excito-motory system, which is often so affected by 
them that the individual reels and falls, while his intellectual functions 
and feelings are so little disturbed that he shows much ingenuity in con- 
cealing his condition and in averting such accidents. 

Alcohol like opium is a narcotic stimulant, but it excites more in the be- 
ginning and stupefies less in the close of its action than that drug. It is, 
therefore, more reliable in cases of extreme exhaustion, and more proper when 
there is deep coma, than opium. In many cases they may be advantageously 
combined, as they have a co-operative but not an identical action. 

Ardent spirit, the most simple, pungent, and active of all the preparations, 
is well fitted for temporary administration in sudden sinkings of the vital 
force. Our physicians are anxious to procure brandy in such cases, without 
knowing that nearly all within their reach is not the genuine eau de vie of 
France, but a factitious compound, rendered stimulating with whiskey or its 
alcohol, and manufactured in the United States. As a general fact it is 
better to rely on old whiskey. The occasional failure of the kidneys to 
secrete, and the more frequent failure of the bladder to excrete its contents, 
suggest the propriety of sometimes preferring gin to either. If diarrhoea 
be present, brandy, from its astringency, may be the best. 

Of all the alcoholic preparations, wine has at all times been the favorite. 
In cases attended with diarrhoea, port is the most proper, even when, as is 
generally the case, it is factitious, for it still contains astringent matters. 
For simply exciting and sustaining the action of the brain and heart, 
Madeira and Sherry are commonly given, and when pure, are unquestionably 
the most genial and salutary of our stimulants. Abounding in acid, they 
may contribute to correct the incipient alkalescence of the blood in the last 



INTERIOR VALLEY OF NORTH AMERICA. 549 

days of the disease, should it exist ; or, disregarding that speculation, and 
desirous of averting the unpleasant or sedative effect of the acids on the 
stomach, they may be neutralized by aqua animonise, or ammoniated alcohol, 
added to such an excess as to be perceptible, but not offensive to the taste. 
When the drowsy and stupid patient is incapable of swallowing many other 
draughts, he will take tablespoonful doses of undiluted wine, if the spoon 
be carried and kept far back on his tongue, and the friends will, in general, 
administer them every ten, twenty, or thirty minutes, when they would not, 
as they express it, " force" a medicine on the feeble and torpid — not reluc- 
tant patient. 

Compared with ardent spirit, wine is nutritious, but beer and porter are 
much more nutritious than wine, while they are tonic from the presence of 
a vegetable bitter, and stimulate less from containing a smaller proportion 
of alcohol. Thus they are intermediate as to wine and gentian or colomba, 
a position which sufficiently indicates the cases in which they may be sub- 
stituted for the latter without loss, or even with advantage to the patient. 

13. Yeast has been long, but not generally, employed in the continued 
fevers. In the systematic treatises of Europe and America, but little men- 
tion is made of it, and most of our physicians I think have never employed 
it. My own experience, and that of my preceptor, long ago, lead me to 
the conclusion that the neglect of this article is not the consequence of un- 
successful trials, and that it deserves more attention than it has received. 
Its modus operandi is perhaps not very obvious. Fermenting poultices im- 
prove the condition of foul and sloughing ulcers, and not only correct the 
fetor of gangrenous surfaces, but appear to aid in arresting the progress of 
that lesion. Thus yeast has acquired the name of an antiseptic or opposer 
of putrefaction, and was administered internally to correct, which to some 
extent it does, the offensive condition of the intestinal contents. It was 
easy, by a parity of reasoning, when petechiae, vibices, and hemorrhages were 
regarded as evidences of a putrescent state of the blood, to believe that 
yeast might correct it, also, and hence its administration when those symp- 
toms were present. It is only when in active fermentation that yeast pos- 
sesses medicinal properties. In that state it liberates alcohol and carbonic 
acid, on which it has been conjectured the effects of this substance depend. 
We are at liberty to suppose, however, that its contact with certain matters 
in the alimentary canal may establish in them an alcoholic fermentation, and 
thus avert one of the putrefactive kind. The influence of yeast on the 
heart and brain is not such as to contraindicate its use in the early stages of 
the fever, or when inflammation exists in the more advanced, and still when 
administered in deeply atonic states of the system, it seems to exert a re- 
freshing and invigorating influence. If diarrhoea be present, it is necessary 
to combine laudanum with it. If the bowels are costive, it will prove aperient, 
and in both conditions may act as a carminative. When the bark seems 
indicated, it may be advantageously combined with this substance. To re- 



550 THE PRINCIPAL DISEASES OP THE 

concile the stomach to yeast, some peppermint or camphor-water may be 
added at the moment of use. An ounce may be given every hour or every 
other hour. Yeast is nutritious, and it seems probable that a portion of its 
benefits may be referred to that quality ; at all events, it leads us in the 
next place to consider the diet of typhous patients. 

14. In the early stages of those cases of typhus which have received 
the epithet synochus, when the heat and thirst are great, with a white tongue, 
and a frequent pulse, not deficient in force, abstinence is indispensable ; yet 
in most instances, it should not be so absolute as in the acute phlegmasiae. 
In subsequent stages, should well-marked inflammation be established in 
any organ, the amount of food should be inversely as the degree of inflam- 
matory diathesis which may be present. With these exceptions the typhous 
fevers are not to be met with great reduction of diet, and as they advance 
the introduction of food into the system becomes an important therapeutic 
object. The long duration of the fever, the reduction of the protein 
elements of the blood, the development ,of urea and probably other elements 
of excretion, and the softening of the tissues independently of inflamma- 
tion, clearly indicate the necessity of supplying new alimentary matter 
through the lacteals. It has been said that the digestive and chylopoietic 
organs are too much enfeebled and perverted in their functions to digest 
and assimilate food ; but we must recollect that it is their natural stimulus, 
under which they may improve in health and strength. If, moreover, the 
chyle which they elaborate should be imperfect, it must still be far better 
for the sanguiferous system to receive it, than to depend for the volume of 
its circulating fluid on the absorption of the slowly decomposing solids. In 
the earlier periods of the fever but a limited quantity, consisting chiefly of 
farinaceous, mucilaginous, and acido-saccharine substances, should be al- 
lowed; but as the fever advances, and the protein elements of the blood 
begin to fail or degenerate, animal broths, jellies, and even fibre should be 
added. Of course all crude and indigestible parts should be excluded, 
and the quantity taken at once should never be great, as it is much better 
to have all digested, than a portion remaining to depress the stomach 
and run into fermentation. Moreover, the irritable condition of the 
bowels renders great caution necessary. The custom sometimes adopted 
of giving small quantities of food at short intervals is not proper, for it in- 
terferes with chymification ; four times in the twenty-four hours, three 
of them being as near as possible to the natural periods of eating, are often 
enough. 



SECTION VII. 

CARE OP THE PATIENT AND HIS CHAMBER IN THE PINAL STAGE. 

I. Bed-sores. — The muscular debility in the latter stages in typhus 
keeps the patient on his back, till in many cases the lower and more pro- 



INTERIOR VALLEY OF NORTH AMERICA. 551 

jecting parts become the seats of extensive ulceration. It is worthy of re- 
mark, that this happens much less frequently when patients are confined in 
the same position from other diseases or from accidents. In the typhous 
fevers, the solids are badly nourished, are softened, and the blood is dete- 
riorated, pathological conditions well fitted to favor the production of these 
lesions, which never present a healthy suppuration and sometimes become 
gangrenous. Being intractable to treatment their prevention is of great im- 
portance. The application of an unirritating adhesive plaster may be of 
some preventive efficacy ; but the only effectual measure is the relief of the 
parts from pressure. This may be done by a pillow or cushion with a cen- 
tral depression or aperture as large as the surface which has begun to red- 
den from capillary stagnation ; but a better method, when it can be com- 
manded, is the India-rubber air or water-bed, which by distributing the pres- 
sure over a larger surface may prevent its bad effects on any. A decoction 
of carrots constitutes a good wash for bed-sores, and the chloride of lime 
in solution a better. On the whole they demand stimulating dressings. 

II. Glandular and cellular suppurations may occur in the progress of a 
typhous fever, and as they do not heal so long as the fever continues, they 
will especially demand attention in the advanced stages. The parotid 
glands are oftenest attacked, and next to them the inguinal. These sup- 
purations are of graver omen than the cellular. In all, the inflammation 
is of an unhealthy character, and the parts sometimes slough extensively 
or become gangrenous. They seem indeed to partake of the carbuncular 
character. I have seen them much more frequently in some subepidemics 
than others. The progress of these suppurations is generally tedious and 
imperfect, from the defibrinated state of the blood and the reduced energy 
of the capillary vessels. These conditions suggest that the treatment should 
be stimulating. Emollient poultices are proper, but they should be ren- 
dered exciting by the addition of honey, soft-boiled onions, aqua aminoniae, 
or a strong decoction of sassafras or carrots, used instead of water, in forming 
them. If applied in a state of fermentation they will be still better. The 
cavities or sloughing ulcers which follow, demand astringent and gently 
escharotic dressings. 

When suppurations of this kin$ occur, it is often necessary to make a 
more liberal use of tonics, especially the bark and opium, than would other- 
wise be required. 

III. Among the pathological occurrences of the advanced and sometimes 
of the convalescent stage of cases in which the glands of the ileum have ul- 
cerated, is the perforation of that bowel. The diagnosis of such a case is 
never difficult. The sudden supervention of pain, greatest in a particular 
part of the abdomen in some cases, but in others, diffused over it; the pain 
being constant but with frequent exacerbations; early tenderness under per- 
cussion ) in most cases a considerable degree of tympanitis ; a cessation of 
diarrhoea if it had existed ) in many instances vomiting ; renewal of tbirst \ 



552 THE PRINCIPAL DISEASES OP THE 

extreme restlessness ; a sinking and extreme frequency of pulse ; a tendency 
to syncope on being set up in bed ; ghastly countenance and early death, 
are characteristic phenomena following on this lesion ; and clearly indica- 
tive of peritoneal irritation and inflammation combined. When the aper- 
ture at the beginning is very small, the first escape of the contents of the 
bowel may excite adhesive inflammation in the surrounding parts and arrest 
a further escape, after which the patient may recover; but such cases are 
extremely rare, and this lesion is generally fatal within forty-eight hours 
after its occurrence. Stimuli will not support the energies of the system 
when they are invaded by the impress of foreign matter on an extensive 
serous membrane; and antiphlogistics, even if the previous condition of the 
patient might have rendered them admissible, are powerless in the reduction 
of an inflammation kept up by the continued presence of its cause. Blis- 
ters are useless, and we are confined to the palliative effects of opium, and 
warm fomentations. 

IV. A retention of urine has been already mentioned as frequently hap- 
pening in the closing stages of typhus. It is impossible for the nurse to 
have accurate information on this point, nor can the patient be trusted, and 
the physician at every visit should carefully explore the hypogastric region 
for a cystic tumor. Diuretics are of little value in such cases and may 
even do harm by increasing the secretion without promoting the excretion 
of urine. The application of a lump of ice above the symphysis pubis will 
sometimes be followed by evacuation ; but on the whole nothing can be 
trusted to but the catheter, which should be introduced once or twice every 
twenty-four hours. 

V. In the exhausted state of the patient in the closing stages of these 
fevers, when diarrhoea is so often present, the patient should never be placed 
on the close stool, which has sometimes been followed by immediate syncope 
and death. He should be required to use the bedpan, or when that is 
found inconvenient be placed on a square of India-rubber cloth which should 
be immediately removed, and thrown into water. Under no circumstances 
should the excretions, uninary or fecal, be allowed to remain in the chamber, 
or put away, as too often happens, in some close, supplemental room. 

VI. In the progress of a fever running on for several weeks, nurses are 
apt to become inattentive to the cleanliness of the sick chamber. It is fre- 
quently kept so dark that small accumulations of filth are not observed ; 
there is a prejudice against washing the floors; the nurse becomes accus- 
tomed to the smells of the room, and ceases to notice them ; finally, as the 
patient gets weaker, and the heat of the body declines, the cool air is very 
•commonly shut out. All this is wrong. The linen of the patient and the bed 
should be changed daily; articles not needed in the room should be sent out; 
the floor should be frequently washed and dried by fire, when the weather 
is not hot and dry, and fresh air admitted freely whatever may be the season of 
the year. The surface of the patient's body may always be protected by 



INTERIOR VALLEY OP NORTH AMERICA. 553 

adequate bed-covering, and the impress of a cool and fresh air on his lungs is 
salutary. It is proper also to wash the surface frequently, and especially 
the eyes and mouth j mucus should not be allowed to accumulate around 
the former, nor sordes on the teeth, lips, and tongue. For this purpose 
there is nothing better than vinegar and water. Unfortunately, the typhous 
fevers prevail most where the necessity for these sanitary domestic measures 
is greatest, and the means of executing them least. 

VII. Deodorizing and Disinfecting Substances. — Chloride of lime, 
nitrate of lead, and chloride of zinc have been employed as deodorizing 
agents. The first was proposed some time since by M. Labarraque ; the 
second and third, more recently, by M. Ledoyen and Sir William 
Burnett. Their power over putrefaction and the offensive odors which it 
generates, is such as to render them useful in the typhous chamber, when- 
ever the source of an offensive smell cannot be destroyed. If not limited 
to such cases, they may do injury by favoring unobserved accumulations of 
filth, from which pernicious gases not decomposable by these agents, may 
arise. The judicious physician will not therefore be forward in recommend- 
ing them to the nurses of his typhous patients. Yet when bed-sores or 
abscesses are offensive between the times of dressing, they may be used, and 
a solution of the chloride of lime or zinc, is, as we have seen, a good wash 
for such surfaces. They may also be thrown into the bedpan and urinal, 
provided that the deodorizing of their contents does not lead to the retention 
of them in or around the chamber. 

The deodorizing property of those agents suggest their employment as 
disinfectants, to which end various experiments have been made, but their 
claims have not been established. Before the discoveries of Ledoyen and 
Burnett, the chloride of lime had lost most of a reputation which at no 
time rested to much extent on anything but its deodorizing qualities. In 
England, some observations and experiments, a few years since, rendered the 
claims of the two other agents so plausible, that in 1847 the British Govern- 
ment sent quantities of both to Dr. Stratton, B. N., to be used at Quebec 
and other places on the St. Lawrence. At the same time M. Ledoyen came 
over accompanied by Col. Calvert, an agent of government, to assist in 
the projected experiments to be made. In the midst of them, M. Ledoyen 
experienced an attack of the fever, from which he recovered, but Col. 
Calvert, less fortunate, fell a victim to the disease. Dr. Stratton conducted 
the experiments with the Burnett fluid, and he published his conclusions.* 
He saw no result indicating a disinfecting property in the Ledoyen fluid, 
while the depressing effect of the lead seemed to be injurious to the patients. 
Three of them kept wrapped in towels dipped in the solution died. As an 
antiseptic deodorant, moreover, its powers were not equal to those of its 
rival, which he found entirely capable of arresting putrefaction and destroy- 
ing all the odors it sends forth. He made some experiments on its capa- 

* British American Journal, vol. i\. p. 31. June, 1848. 



554 THE PRINCIPAL DISEASES OF THE 

bility of improving the atmosphere of the Marine Emigrant Hospital in 
Quebec, and obtained as results, one death daily for fourteen patients, in 
the wards where the fluid was used; in those from which it was withheld, 
one death daily of nine patients. This difference tallies very well with the 
alleged diminution of mortality from fever in some of the British ships 
and hospitals.* Still, Dr. Stratton does not venture on the conclusion that 
the Burnett fluid is a true disinfectant, nor was he able to test it in the 
mode necessary to a final decision. Being in Quebec at the time he received 
the fluid, I heard him remark very properly, that the true method would be 
to use it on board the emigrant ships, where, if it possessed a disinfecting 
power, it would prevent or arrest the spread of the fever. 
'' Experiments of the same conclusive character might be made in private 
practice, in the country, especially where several or all the members of a 
family occupy one or two apartments, and from which the first patient is 
never sent to a hospital. Should an early resort to this agent, no special 
attention being given to cleanliness or ventilation, be found in a large 
number of families to limit the disease to the first patient, while in others, 
during the same epidemic, and in similar circumstances in which it was not 
used, the fever attacked several members in succession, the corrective and 
preventive power of this agent would be established. Yet it would remain 
to be ascertained whether it had acted on a contagious secretion exhaled by 
the patient, or a malaria developed within his dwelling. 



CHAPTER XVI. 

RELATIONS OF TYPHOUS FEVERS WITH YELLOW, REMITTENT, AND 
OTHER FEBRILE DISEASES ; SECONDARY TYPHUS ; TYPHOID STAGE. 



SECTION I. 

YELLOW AND TYPHOUS EEVER : ICTERO-TYPHOUS.f 

1. Differences. — 1. Yellow fever is a disease of hot climates, and in 
our Valley has not yet ascended beyond the 35th degree of latitude, where 
the mean heat of summer is about 80°, and that of the year 70°. 

The typhous fevers prevail more in the higher than the lower latitudes, 
and as indigenous diseases are almost unknown where the heat of the year 
and the summer rise above the degrees just given. 

2. Yellow fever in our Valley, prevails most on low levels near the sea — 
is littoral — and has not occurred at an elevation of more than 400 feet. 

* British American Journal, vol. iii. p. 303, March, 1848. 

f Before perusing this chapter, the reader would do well to look over the parallel between yellow 
and remittent fever, Book II. Part II. Chap. I. 



INTERIOR VALLEY OF NORTH AMERICA. 555 

The typhous fevers are essentially continental, and prevail in the Apa- 
lachian Mountains and those of the territory of Santa Fe. 

3. Yellow fever occurs almost exclusively in our cities and towns; 
typhous fever on the other hand, prevails equally in town and country. 

4. Yellow fever generally occurs as an epidemic, and in the northern 
portion of its zone is never sporadic : typhous fevers on the contrary are 
both epidemic and. sporadic in every region which they infest. 

5. Yellow fever within our Valley scarcely ever sets in till after the 
summer solstice, and as constantly ceases before the winter, being at its 
height about the autumnal equinox. Typhous fevers occur sporadically 
throughout the year; and have been epidemic in every season. 

6. The onset of yellow fever is generally sudden and violent — that of 
typhous fevers slow and insidious. The ordinary duration of one is five or 
seven days — of the other three times that period. 

7. A cutaneous maculation or efflorescence is a frequent event in typhous 
fevers, but is absent in yellow fever. 

8. Prolonged yellow fever is almost unknown; but a short and fatal 
typhous fever is not very uncommon; it does not, however, display the 
symptoms characteristic of yellow fever. 

9. In the closing stage of yellow fever there is suppression of urine; in 
that of typhous, retention, with broad exceptions to both. 

10. Typhous fevers are sometimes contagious : yellow fever never. 

11. The closing stage of yellow fever is attended with the black vomit — 
that of typhous fever not.* 

12. The most striking morbid appearances in yellow fever are found in 
the stomach, duodenum, and liver : — in the typhous fevers in the brain, 
lungs, ileum, and spleen. 

13. Yellow fever is followed by quick and perfect recovery — typhous 
fevers have a slow and imperfect convalescence. 

II. Identities or Analogies. — Both are continued fevers : both are 
accompanied with hemorrhages in the latter stages : both confer an imper- 
fect and uncertain immunity from a second attack : both originate and 
become epidemic in certain but not the same localities : both appear at 
times to be introduced : both originate in ships at sea, but not often when 
they were sailing in the same latitudes : finally, both seem to run, respec- 
tively, a destined course, in despite of medical interference. 

III. Union op Diathesis. Ictero-typhous. — Were the climatic and 
topographical relations of yellow and typhous fevers less diverse, we should 
doubtless see them oftener conjoined than we now do. 

[MSS. wanting.— Ed.] 

* The closing stage of yellow fever is generally unattended with delirium — that of the typhous fever 
always with delirium or impassibility — abolition of intellect. 



556 THE PRINCIPAL DISEASES OP THE 

SECTION II. 

REMITTENT, AUTUMNAL, AND TYPHOUS FEVERS. 

1. Diversities. — Remitto-typlwus : typhoid stage of remittent fever. — 1. 
A mean annual temperature below 40° with a summer mean heat below 
60°, extinguish remittent autumnal fever; but are not incompatible with a 
general prevalence of the typhous fevers. The former is epidemic only in 
autumn — the latter in every season. 

2. Extended dryness of surface, the absence of decomposable organic 
matter, and circumstances characterizing the densely populated portions of 
our larger cities, greatly diminish, or prevent autumnal fever, but not 
typhous. 

3. Typhous fevers are sometimes contagious, — sometimes introduced, — 
autumnal remittents never. 

4. The natural termination of remittent fever is in intermittents ; but 
not so with typhous. 

5. One attack of remittent fever predisposes to another; but it is other- 
wise with typhous. 

6. The copious secretion of bile and derangements of the biliary function 
so characteristic of remittent fever, are absent in typhous. 

7. The maculas in typhous do not occur in remittent fever; and hemor- 
rhages are rarer. 

8. The coma, subsultus, sordes of the teeth, and dry red tongue of 
typhus, are not necessarily present in remittent fever. 

9. When both assume a malignant character and prove fatal within a 
few days, the assemblage and succession of symptoms is not the same. 

10. The sulphate of quinine arrests remittent fever, but not typhous. 

11. The pathological appearances in remittent fever are mainly in the 
stomach, duodenum, spleen, and liver — those of the typhous fevers more in 
the ileum, brain, lungs, and spleen ; though there are many exceptions to 
both rules. 

II. Resemblances, or Identities. — In many cases the access or forming 
stage is nearly of the same length in both ; and sliding into an intermittent 
type, the remittent may endure as long as a protracted typhous fever. 

1. Both may have a full epidemic development in the same climates, 
whether on land or sea. 

2. In the early periods of the stage of excitement, the remittent may ap- 
proach so closely to a continued type, that the two fevers may be confounded. 

3. Both attack males more than females. 

4. "When remittent fever terminates fatally in one or two weeks, a certain 
amount of subsultus, a dryness of the tongue, and intestinal hemorrhage, 
are sometimes present, although no typhous fever may be prevailing in that 
locality, and this brings us to inquire, not into the distinctive peculiarities 



INTERIOR VALLEY OF NORTH AMERICA. 557 

of these two forms of fever, but into their combination, into the hybrid or 
mongrel diathesis which results from the joint impress, in ever-varying pro- 
portions, of the causes which produce true typhous and true remittent fevers. 

III. Remitto-Typhous or Secondary Typhous Feyer. — Typhoid 
Stage of Autumnal Fever. — I do not recollect to have seen a case of fever, 
well-marked as typhous in the early stages, terminate as an intermittent ; 
nor a decided intermittent degenerate into a typhous. The union is between 
remittent and typhous, specimens of which, both sporadic and epidemic, 
present themselves every year. Repeated references have been already made 
to them. 

This mingling has led some speculative men to assign them a common 
cause, and to constitute them a single species. But such a coalition would 
not be made by one who had been familiar with both forms, and had the 
pathognomonic characters of each impressed on his mind by sporadic and 
epidemic cases, when the other was entirely absent. We know a febrile 
diathesis by its phenomena, its relation to remedies, and its post-mortem 
lesions. Thus tested, the diathesis of primary typhous and that of periodical 
fever, are as distinct from each other as the diathesis of measles is from 
that of scarlet fever, or exotic epidemic cholera from our endemio-epidemic 
cholera morbus. Yet measles and scarlatina may prevail at the same time, 
and modify each other; and throughout the present, as well as the two 
preceding summers (1849-50-51), many cases in various parts of our 
Valley, which commenced as endemial cholera morbus, diarrhoea, or dysen- 
tery, terminated as epidemic cholera. If the remote cause of the latter 
were annually and permanently reproduced among us, like that of the former, 
we should every summer have such cases, and might at last conclude that 
but one remote cause existed; and, to borrow a chemical expression, that 
the disease was a simple element, instead of a binaiy compound. The 
chalk and mercury which the young student of pharmacy triturates together, 
seem to him equally simple, yet the chemist knows that the former is a 
compound, because he has resolved it into three elements, studied them 
separately, and reunited them into chalk. We cannot thus analyze morbid 
actions, but nature presents us with their uncombined elements — indigenous 
cholera, when the foreign has been long absent, and the latter, in the depths 
of winter, when the former never occurs. By thus studying them apart 
from each other, we learn the characters of each, and when they unite in 
the production of a compound malady, we can follow them as the chemist 
follows his elements, when he synthetically combines them; and point out, 
as he can, the contributions of each to the tertium quid. 

\Te have but to examine the fevers now before us by the light of this 
illustration to recognize the presence of two elements, the periodical and 
the continued, and thus be prepared to expect, that as they vary in their 
proportions, the phenomena resulting must vary. In chemistry, many sub- 
stances will combine only in definite proportions. This is the case with the 



558 THE PRINCIPAL DISEASES OF THE 

phosphoric acid and lime of the bones ; but others, as water and alcohol, 
will combine in all proportions ; and they represent to us the union of the 
typhous and the periodical elements of the fevers now under consideration, 
which, in fact, mingle indefinitely. Thus we sometimes see a typhous fever 
with such a morning abatement as inspires hopes of an early intermission, 
and the successful use of the sulphate of quinine, which nevertheless may 
fail. At other times we have an early development of typhous symptoms, 
when the locality and season of the year clearly indicate the presence of the 
remote cause of autumnal fever. In some autumns, almost every case ter- 
minates by crisis, or in the intermitting type ; in other seasons, a large pro- 
portion, after the first week, display a typhous character. In the high 
latitudes or altitudes, the type of the fever may be continued, and yet show 
its relation to periodical fever by prevailing chiefly in the latter part of 
summer, and in early autumn, and by terminating without the characteristic 
symptoms of typhous in the second week, corresponding to the time when 
remittent fever often terminates by a crisis, or in the intermittent form. 
This is the synochus of the St. Lawrence, an autumnal fever in which the 
periodical element is feeble, and the typhous not malignant. 

I have already said that in some autumns only here and there a case of 
remittent fever, in its progress, assumes a typhous character ; while in 
other seasons in the same locality a large proportion take that course. Now 
is the pathological character of the sporadic and the epidemic cases the 
same ? As far as we may rely on the symptoms it is. At least I have not 
been able to detect a difference, nor am I aware that any of our physicians 
have. It would appear, then, that the occult agencies which modify the 
type of our autumnal fever, may be developed on a most limited, or a most 
enlarged scale, which being also the law of primary typhous, brings us 
through etiological views to the conclusion, that secondary or remitto- 
typhous depends on the same cause with primary, acting in concert with 
the cause of remittent fever. It appears, still further, that within the lati- 
tude in which typhous fever occurs, its cause or causes are more or less 
developed every autumn. There is, however, another view of the origin 
of sporadic secondary typhous, which ascribes it to the treatment pur- 
sued in remittent fever. Thus the premature administration of tonics 
and stimulants, developing a low cerebral inflammation ; copious bloodletting, 
producing constitutional irritability with vascular inanition ; and drastic 
purging, raising an irritation in the alimentary mucous membranes with 
general exhaustion, have all been charged with producing the pathological 
state we are now studying. That they may contribute to it, is, I think, 
extremely probable ; but we all know that these active measures have been 
often employed, without being followed by secondary typhous ; and that it 
has supervened when none of them were used. Something else seems there- 
fore to be in action. 



INTERIOR VALLEY OP NORTH AMERICA. 559 

SECTION III. 

TREATMENT OF SECONDARY OR REMITTO-TYPHOUS FEVER. 

I. At all times the aspect of our autumnal remittent fever, called its 
typhoid* stage has been regarded with deep concern by the physicians resid- 
ing above the thirty-third degree of latitude : below that it is comparatively of 
rare occurrence. Its development generally begins in the second week, and 
one of its earliest manifestations is a shortening of the morning remission 
when it should be lengthening ; at the same time, the tongue, previously 
covered with a moist, white, or yellowish fur, begins to dry, and the fur as- 
sumes a dead-leaf color; the cheeks display a circumscribed dark or .dusky 
hue ; the patient becomes more composed, and at length, whenever his atten- 
tion is not engaged, begins to doze ', in that condition but not when wide 
awake, a slight subsultus tendinum may be perceived ; a low delirium soon 
begins ; the heat of his skin continues and often becomes more pungent, 
and his pulse increases in frequency though not in fulness or force. The 
biliary dejections characteristic of remittent fever often diminish or entirely 
cease, and the discharges, sometimes diarrhoeal, become more offensive. 

The progress of development of these symptoms is various. I have seen 
many of them occur with severity in a single night, giving a new morning 
aspect to a case which seemed likely to present an intermission ; and I have 
also seen them slowly developing through several days. In some cases the 
sallow or jaundiced hue of the remittent diminishes, in others it continues or 
even increases ; and sometimes it does not show itself, till after the typhous 
symptoms have set in. It is not necessary to trace out these symptoms to 
the close. In many cases they continue mild, and at length show such a 
morning remission, as proves that the periodical diathesis is not extinct. In 
others, however, they are regularly ingravescent, till the patient is brought 
into a condition which cannot, I think, be distinguished from primary 
typhous. 

II. Treatment of Remitto-typhotjs. — During the reign of a typhous 
atmospheric constitution, the evacuant and debilitating treatment, which, 
in simple and inflammatory remittents, is safe (although not required to 
the extent to which it has been carried), should be employed with reserve. 
Emetics are proper, but purgation should not be urged beyond the degree 

* It is certainly to be regretted, that a writer so popular and authoritative as Louis, should have 
wrested this term from a place in which it was technically standing, and designated a secondary 
typhous state, to apply it to a primary fever which he was laboring to prove was specifically distinct 
*from the typhus mitior of the nosologists. If he and his school should succeed, it would violate the 
principles of philosophical nomenclature to retain that name ; and if they should not, we are brought 
into the predicament of using the same term for secondary, and for one of the primary modifications of 
the same fever. Every day's intercourse and correspondence with our physicians gives me new evi- 
dence of the extent to which this term is superseding the long-established word from which it is derived. 
Indeed, that term seems likely to become obsolete, not being able to hold its own against another formed 
out of it, and destitute of meaning when not taken in connection with it. 



560 THE PRINCIPAL DISEASES OF THE 

which is required for a complete evacuation of the bowels, in the early stage. 
Local bleeding may be proper, but in general is seldom admissible. The 
best alterative is tartarized antimony; should the biliary derangements be 
great, calomel may be given in alterant doses, but should not be continued 
to the production of constitutional effects. Cold water may be used freely, and 
sudorifics with gentle anodynes administered at night. Under the use of 
these mild means, decided remissions eventuating in intermissions are looked 
for, and sometimes occur, when the bark or sulphate of quinine may termi- 
nate the fever; not unfrequently, however, it goes on to a full development 
of the " typhoid stage" or secondary typhous; and a better plan is a deside- 
ratum. Such a method, is, I think, to be found in what I have presented, 
Book II. Part I. as an improved mode of treating ordinary remittent fever. 
It consists in the nearly total omission of everything just enumerated, but 
the lancet and a simple aperient, employing the former early, and drawing 
blood till syncope impends. Then administering a liberal dose of sulphate 
of quinine and opium, or Dover's powder. If the typhous diathesis can be 
met at all by the quinine, it will be under such circumstances. If it should 
not succeed, the full development of the " typhoid stage" follows as a 
matter of course. The successful management of this stage demands both 
sagacity and patience. The vital susceptibilities and forces are reduced, 
and the solid tissues relaxed and softened ; the blood is impoverished and 
deteriorated, the secretions are suspended and depraved, and in many cases 
some organ — as the brain, the ileum, or the lungs, — is in a state of sub- 
acute inflammation. Tonics, stimulants, and nutrients are demanded, yet if 
actual inflammation be present, they must be withheld until by local bleed- 
ing, watery affusions, or blisters, the inflammation is brought down. Even 
when it does not exist, corroborants and restoratives may fail or prove mis- 
chievous, if the secretions and excretions, especially those of the skin, liver, 
and bowels should not be re-established. To their re-establishment, it is 
true, tonics and food often contribute in a decided manner, but they also 
fail, and render a resort to stimulating diaphoretics, cholagogues, and 
aperients indispensable. Stimulation without secretion cannot be con- 
tinued with impunity. But it is superfluous to go into the details of this 
treatment, seeing that it is substantially the same as that already indicated 
for the advanced stages of primary typhous fevers.* 



SECTION IV. 

TYPHOUS COMPLICATION WITH VARIOUS OTHER DISEASES. 

At times the typhous diathesis or type manifests its presence in various 
febrile and other diseases, besides yellow and remittent autumnal fever ; but 

*For a more extended account of the proper treatment of the "typhoid stage" of our autumnal 
fevers, the author begs leave to refer to an article of his own in the Western Journal of the Med. and 
Phys.Sci. (Cincinnati), vol. i. p. 381, A.D. 1827. 



INTERIOR VALLEY OF NORTH AMERICA. 561 

these complications must be studied when we reach those maladies. The 
most important are pneumonia and some other of the phlegmasiae; the prin- 
cipal eruptive fevers as measles, scarlatina, and small-pox ; dysentery, puer- 
peral fever, scorbutus, and erysipelas. This complication always modifies 
their symptoms and treatment unfavorably ; never simplifying the former, 
nor contributing to a better result from the latter. 

Sometimes these complications are sporadic, at other times epidemic 
following the same law of prevalence as the 'primary typhous fevers. As a 
general fact, we may say that the typhous diathesis has preceded the other, 
and so modified or degraded the constitution, that when the causes of those 
different maladies have awakened them, their symptoms, course and termi- 
nation give them an aspect and an intrinsic pathological character, which 
assimilates them to the typhous fevers. 

Of these pathological compounds, one which sometimes occurs sporadically, 
but has also, as we saw in Chapter I. of this Part, appeared as a wide-spread- 
ing and fatal epidemic, is pneumonia. Still further, during the reign of an 
epidemic typhous constitution, all the phlegmasiae are more or less modified 
by it, so that the antiphlogistic treatment which they ordinarily require is 
no longer admissible, except in a limited degree. Of the pernicious influ- 
ence of this diathesis in the true eruptive fevers, every experienced physi- 
cian is fully aware. It is common to speak of those fevers as being mild 
or malignant from variations in their respective remote causes, but we 
cannot thus view pneumonia, because its specific remote cause, atmospheric 
condition, does not vary, and hence it seems more reasonable to ascribe the 
grave, adynamic, and ataxic character in which those epidemic exanthemata 
sometimes appear, to a previous lesion of the constitution produced by the 
typhous poison. The same reasoning applies to puerperal fever, which is 
ordinarily a simple phlegmasiae of the serous membranes of the pelvis and 
abdomen, but at times a formidable fever of a typhous physiognomy. 

In dysentery the same dangerous tendency to a typhous condition is 
sometimes sporadic ; at other times epidemic, when it becomes one of our 
most fatal maladies. 

It is perhaps in erysipelas, whether sporadic or epidemic, traumatic or 
idiopathic, that we most frequently observe a typhous tendency. If this 
malady cannot be classed with the phlegmasise, to which in many instances 
it is closely allied, it never exists without inflammation. Yet the erysipe- 
latous fever is not as phlogistic as that accompanying the true phlegmasise, 
and in all cases the physician regards the development of typhous symptoms 
as an unwelcome event, which may possibly happen. 

With these notices of the blendings of a typhous diathesis with various 
forms of disease hereafter to be studied, the author takes leave of the con- 
tinued or typhous fevers. He has endeavored to present an outline of 
their causes, symptoms, and modes of treatment in our Interior Valley, 
and to discuss their etiology, nosology, pathology, and therapeutics, by the 

vol. ii. 36 



562 THE PRINCIPAL DISEASES, ETC. 

facts furnished by this, with, to some extent, several other countries. He 
confesses that he has found the discussion difficult ; and is not satisfied with 
all the conclusions at which he has arrived. A deeper knowledge of the 
organization, vital properties, and functions of the healthy body, a more pro- 
found acquaintance with the relations between that body and the external 
agents which act upon it; an acuter discrimination among the types of 
morbid action, and a keener analytical sagacity, would have given results 
of a more reliable kind. He has but enlarged the opening of a new quarry, 
and brought forth some materials for such a future architect, and must 
therewith be content. 



PART FOURTH. 
ERUPTIVE FEVERS, 



INTRODUCTION. 

By a transition which may almost be called natural, which at least is 
neither abrupt nor arbitrary, we pass from the typhous fevers to the erup- 
tive. This may be shown in a few paragraphs. 

1. In both groups the fever has a continued type, and in general cannot 
be arrested by art. 

2. Inflammation commonly occurs in connection with the fever, but in 
malignant and early fatal cases, in both groups, death may occur without 
inflammation. 

3. In harmony with this is the fact, that the fever, with occasional excep- 
tions, precedes the inflammation in both groups. 

4. In the respective members of each group, there is some particular sur- 
face or tissue which is the seat of the characteristic inflammation, yet 
various and many other parts are liable to that affection in the course of the 
fever ; and the danger, when death does not occur, as already stated in the 
beginning, is in proportion to the extent or intensity of the inflammation, 
taken in connection with its seat. 

5. As a pathological fact common to both the typhous and eruptive 
groups, the inflammation partakes more of the character of simple or pas- 
sive congestion, is less acute, the hyperinosis of the blood is less developed, 
and the phlogistic diathesis of the organism is less intense, than in the true 
phlegmasiae which compose the next group. 

6. In the typhous fevers, maculae and efflorescences occur in a large 
number of cases, giving to these a close resemblance to certain eruptive 
fevers. 

7. Some members of both groups are unquestionably contagious, while 
others are not. 

8. An epidemic prevalence is common to (nearly) the whole of both 
assemblages ; and while some of the eruptive fevers, as small-pox, never 
appear sporadically, others, as urticaria and erysipelas do. 



564 THE PRINCIPAL DISEASES OF THE 

9. A reigning typhous constitution does not exclude the eruptive fevers, 
but modifies them perniciously. 

10. Contagious typhous fevers sometimes have an immediate local origin ; 
and the same is true of erysipelas and apparently of scarlatina. 

In proceeding to treat of the eruptive fevers, erysipelas should perhaps 
be first introduced, as having the closest resemblance to the typhous fevers ; 
but as it has an equal affinity with the phlegmasise or phlogistic fevers, it 
may with nosological propriety be placed next to them, and thus constitute 
the connecting link between them and the group we are now about to study. 
There is, moreover, a philosophical propriety in beginning with the most 
noted member, that which gives distinctive character to the group, and I 
shall, therefore, commence with the small-pox. 

As the most important of the eruptive fevers arise from specific poisons, 
and are not greatly modified by geological, topographical, climatic, or social 
influence, this part of our work will of course present less of what is peculiar 
to our Interior Valley than the three through which we have passed ; and 
must consequently assume more of the manner of a systematic work on the 
theory and practice of medicine. Greater conciseness will be, therefore, 
both practicable and proper. As to the number of maladies to be intro- 
duced into this Part it cannot be great. The reader must not carelessly 
confound the import of the phrase eruptive fevers with the expression cuta- 
neous diseases, and expect to see the whole introduced here, for he will find 
only those which are accompanied with fever. 

As to a classification of these maladies, it is not perhaps of much import- 
ance, as they differ so much from each other, that each must be studied 
apart from the rest by the practical physician, yet as any kind of order is 
preferable to disorder, I shall class them as follows : — 

Division I. — Vesico-Ptjstular. 

Variola, — Small-pox. 
Vaccinia, — Coio-pox. 
Varioloid, — Modified Small-pox. 
Varicella, — Chicken-pox. 

Division II. — Exanthematotjs. 
Rubeola, — Measles. 
Scarlatina, — Scarlet Fever. 
Roseola, — Rose-rash. 
Urticaria, — Nettle-rash. 

Division III. — Erythematous. 

Erysipelas Sporadica, — Sporadic Erysipelas. 
(i Epidemica, — Epidemic Erysipelas. 



INTERIOR VALLEY OF NORTH AMERICA. 565 

CHAPTER I. 

SMALL-POX [VARIOLA]. 



SECTION I. 



PREVALENCE AND ETIOLOGY. 



Prevalence. — As the greater part of the Interior Valley has been settled 
since the discovery of vaccination, small-pox has never prevailed as a wide- 
spreading and mortal epidemic. Nevertheless, it has visited most of the 
towns which lie on the highways of intercourse, where, even down to the 
present time, it has never failed to excite alarm, and lead to measures for 
secluding the infected, and thus limiting the spread of the disease. Its 
visitations have not been confined to particular latitudes, but have occurred 
from Lake Superior to the Gulf of Mexico ; yet they have, I think, been 
more frequent and fatal in the North than the South, owing, perhaps, partly 
to the influence of climate, and partly to the greater number of towns 
and freer intercourse between them in the former than the latter. It 
has also penetrated far into the wilderness, and proved extremely mortal 
among some of the Indian tribes. Whether it has ever prevailed among 
us as an epidemic, originating independently of contagion, I am unable 
to say. We know it only as an introduced and contagious malady, which 
sometimes spreads much more than at others. Inoculation was never 
generally practised in the Valley, and before, perhaps even since the intro- 
duction of vaccination, the spread of natural small-pox has been restrained 
more by non-intercourse with the sick than in any other way. A majority 
of our physicians have never treated or even seen a case of small-pox ; and 
many of them, notwithstanding their vaccination, would prefer not to visit 
a patient laboring under that disease ; nor would any class of our medical 
students permit a clinical professor to bring a small-pox patient before them. 
This manifestation of a want of confidence in vaccination, contributes to 
perpetuate the popular incredulity of which it is a part, and justifies this 
notice, which is designed to recall attention to a violated duty. 

But little modified by climate or states of society, and amply discussed 
in its diagnosis and treatment by all the systematic writers, I shall, in this 
article aim at nothing more than a condensed practical history of the disease, 
unencumbered with the citation of many authorities, either foreign or 
domestic. 

Etiology. — Although small-pox has in some countries appeared to 
begin or prevail independently of contagion, in this we know it only as 
the offspring of that agent. 1. The exhalations from the body of a patient 
laboring under the initiatory fever may occasion the disease. 2. The ex- 



566 THE PRINCIPAL DISEASES OF THE 

halations from the pustulated surface are a still more certain cause. To 
what distance they may spread and still be sufficiently concentrated to gene- 
rate the disease is uncertain. Doubtless the amount of infection exhaled, 
and the degree of ventilation will materially influence the result ; but in 
general the radius of the infected atmosphere may be expressed by feet 
rather than yards. 3. The scabs or clothes impregnated with the discharge 
from pustules may communicate the disease long after they have been de- 
tached, if they have not been exposed to the decomposing influence of a 
very high or a very low temperature. 4. The exhalations of the patient 
absorbed by fomites may propagate the disease, but at a less distant period 
than solid matter. 5. The disease may, as all the world knows, be propa- 
gated by inoculation, to which end an exceedingly small quantity of matter 
is sufficient. Whether the milder character of small-pox under inoculation, 
is owing in part to this cause or wholly to the previous preparation of the 
patient, is not, perhaps, a settled point, but from analogy we may conclude, 
that cmteris paribus, the violence of the malady will be in proportion to the 
amount of the remote cause. Nevertheless, violent and confluent cases have 
resulted from exposure to those of the mildest kind, et vice versa. The 
length of time which elapses after the impress of the remote cause, before 
the commencement of the initiatory fever is not uniform. The range of 
variation may be stated at a week. Thus the fever rarely if ever supervenes 
before the seventh day, and may be deferred to the fourteenth. It is a 
popular opinion that the ninth is most frequently the day of commence- 
ment, but the experience of the profession rather decides in favor of the 
eleventh, twelfth, or thirteenth. It does not appear that the disease mani- 
fests itself at an earlier period after exposure to concentrated than dilute 
infection. In some cases of the former kind an immediate undefinable in- 
disposition has followed the impress of the poison; the fever being deferred, 
however, to the usual period of access. In a great number of instances 
the stage of incubation is unattended with any indisposition. 



SECTION II. 

SYMPTOMS. 

Eruptive Fever. — If those who have had an ample experience in 
small-pox cannot with much certainty recognize the effect of its contagion 
in the symptoms which characterize this stage of the disease, the physician 
who sees it but seldom, will observe little else than a simple inflammatory 
fever unaccompanied by any manifest local inflammation. One long, or a 
series of short chills are followed by violent reaction, characterized by thirst, 
a white tongue, heat, an active — often a tense — pulse, restlessness, severe 
head and backache ; epigastric pain, nausea and vomiting ; occasionally 
delirium ; in children a certain degree of drowsiness, and not uncommonly 



INTERIOR VALLEY OF NORTH AMERICA. 567 

one or more convulsions. On the second day the continuance of the fever 
indicates it not to be of malarious origin, while the diffusion of the pain and 
aching through the head, back and limbs, and the want of manifest concen- 
tration of morbid action in any particular organ, will suggest that the disease 
is not~a simple phlegmasia. In the course of the third day it becomes ap- 
parent that the patient labors under one of the exanthemata ; but which, 
cannot always be told from the appearances. The absence of catarrhal 
symptoms, however, will indicate that it is not measles ; and the absence 
or great mildness of the anginose symptoms, taken in connection with the 
want of efflorescence on the neck and breast, will with almost equal certainty 
show that it is not scarlatina. With the outbreak of the eruption the fever 
begins to abate, and the patient becomes more comfortable. 

Eruption. — This shows itself in the form of red elevated points or 
papulae, which in nearly every case show themselves first on the face, and 
progressively on the neck, arms, trunk, thighs, legs and feet, seldom reach- 
ing the last under two days from the beginning of the eruption, by which 
time the eruptive fever generally ceases. When the papulse are not very 
numerous, the case is denominated distinct or discrete, and the danger is 
small j when very numerous and crowded so as to run together, it is called 
confluent, and is always dangerous. The eruption is not limited to the skin, 
but extends more or less to the mucous membrane of the air-passages, from 
the alae nasi to the bronchial tubes, and from the lips to the oesophagus. 
That of the stomach and bowels is not often or much affected ; and accord- 
ing to the testimony of the best observers, notwithstanding the eyes are 
often severely attacked in a subsequent stage of the disease, they are seldom 
the seats of eruption. 

The progress of the papulae is to vesicles with inflamed bases and indented 
centres ; then to pustules, which at length lose the indentation and assume 
a hemispherical form, except in the confluent variety, where their number 
interferes with a regular development. Each pustule before it arrives at 
an advanced stage comprehends a number of cells, formed by membranous 
partitions, which radiate from its centre. These are broken down with the 
progress of suppuration, until at length a single cell or cyst only remains, 
which by careful dissection may be lifted out of its bed in the cutis vera. 
The progress of maturation follows that of the efflorescence, so that it is 
completed first on the upper parts of the body. When the pustules are 
fully formed the cuticular covering gives way and the contents gradually 
flow out, at the same time hardening into scabs, which generally takes place 
in seven or eight days from their appearance. In mild and discrete cases, 
although the itching of the skin may torment the patient, there is seldom 
any fever during the scabbing and exfoliation, and recovery is for the most 
part rapid and favorable. 

Such are the course and termination of distinct or benign small-pox : the 
confluent variety presents an aspect far more loathsome and dangerous. In 



568 THE PRINCIPAL DISEASES OF THE 

this grade the eruptive fever is decidedly more violent, and the brain is 
often so deeply involved, that the disease might be mistaken for a primary 
inflammation of that organ. The papulae, which appear rather earlier than 
in the other variety, are so numerous as to give to the face, on which they 
are first seen, and on which they most prevail, a uniform redness, but 
unable from interference to develop themselves, the areolas which surround 
the discrete pustules is not formed, and very soon the surface takes on a 
whitish appearance from the secretion beneath the cuticle. The inflamma- 
tion descends into the skin, and often invades the cellular tissue beneath. 
Few or no centrally depressed or umbilicated pustules are formed, but all 
the parts over which the confluent eruption extends become invested, as it 
were, with a fictitious integument. Great swelling, of course, takes place, 
especially of the head and face, so that the eyes are sometimes entirely 
closed. The mucous membranes, already enumerated as liable to variolous 
eruption, suffer almost equally with the skin, and great nasal or laryngeal 
difficulty of breathing, and much difficulty of deglutition, ensue. The 
quantity of purulent secretion is very large, and ultimately forms an incrus- 
tation, which, exfoliating, presents a surface beneath of a raw, purple, or 
livid appearance, often deeply and permanently pitted. During the whole 
progress of this maturation the eruptive fever continues, and thus consti- 
tutes a distinguishing character of this variety, compared with the mild and 
discrete form, in which it ceases on the appearance of the efflorescence. In 
eight, nine, or ten days after the first appearance of the eruption, the disease 
often terminates fatally. In some the state of the larynx interferes with 
respiration, and destroys life by impairing that function j in others death is 
the consequence of lesions of the brain ; in others there is general exhaus- 
tion of the vital forces, with extensive cellular suppurations, sloughings, or 
gangrene. Should the patient survive these accidents, new dangers await 
him. As the scabbing commences, the fever revives, and, under the name 
of secondary, often proves fatal. This is generally most violent when the 
affection of the mucous membranes has not been great, but the cellulitis and 
subcutaneous suppuration violent. The pustulated surface becomes hard 
and scaly, the pulse extremely frequent, the thirst intense, and the skin 
hot. Occurring in an exhausted system, and apparently produced by the 
reactive influence of the pus, which, as it were, saturates the dermoid tissue, 
this fever is of a true adynamic or typhous character, and is accompanied 
with local affections of the gravest kind. The mucous membranes, and the 
skin from which the incrustations have been detached, often assume an erythe- 
matous or erysipelatous hue, and vesications arise which sometimes become 
gangrenous; diffuse suppurations, or gangrene of the cellular substance, 
rapidly supervene; the lymphatic ganglia become the seats of abscesses; 
the eyes, of an inflammation which too often ends in sloughing and total 
blindness of one or both; cerebral inflammation, not unlike that which 
supervenes in the advanced stages of autumnal fever, sets in ; and the lungs 



INTERIOR VALLEY OF NORTH AMERICA. 569 

often become the seats of an inflammatory congestion, not unlike that which 
constitutes our typhoid pneumonia. Should the patient survive this stage 
of the disease, he may still be pursued by chronic disorders of an afflicting 
or ultimately fatal character. These are indurations or even suppurations 
of the ganglia of the neck; earache, or ulceration of the auditory passages; 
chronic ophthalmia, with ultimate closure of the pupil; lastly, a fatal 
phthisis. In all of these cases there is a strumous taint which the small- 
pox has aroused into activity. 

Sporadic cases of confluent small-pox occur, as the consequence, no doubt, 
of peculiarity of constitution or improper treatment in the early stages ; but 
at times a whole epidemic has shown that tendency, while another has 
been as generally mild and discrete. These differences can only be referred 
to prevailing or epidemic constitutions of the atmosphere. When, for 
example, a typhous constitution obtains, small-pox may be expected to 
assume a confluent character; and it is in the fullest development of such a 
constitution that it displays not only the symptoms which have been de- 
scribed, but hemorrhages, petechise, and other signs of malignity, which, in 
some cases, replace the eruption, and obscure the diagnosis of the disease. 



[SECTION III. 

PATHOLOGICAL ANATOMY.* 

1. Nervous Centres and their Envelopes. — In proportion to the disturb- 
ance of the functions of the brain during life, accompained with high fever 
and swelling of the head and face, especially if the patient expire comatose 
or in convulsions, the blood-vessels of the brain and its envelopes are found 
distended, with serous effusion beneath the arachnoid, into the ventricles 
and spinal sheath. These lesions are evidently common to various disorders. 

2. Organs of Respiration and Circulation. — The mucous membrane 
lining the air-passages presents morbid changes from the nostrils to the 
minor bronchial divisions. Thus it is found reddened, injected, swelled, 
pulpy, black, and sloughy, covered with an abundant gray or brown, thick, 
tenacious, puriform secretion. False membrane, white or gray, thin and 
paper-like, and easily separable, is occasionally found lining the trachea and 
bronchial tubes. With the exception of the minor evidences of previous 
congestion, these appearances are peculiar to small-pox, proving fatal from 
the fourth to the fourteenth day after invasion. 

The lungs are engorged, displaying hepatization, purulent infiltration, or 
abscess; the pleura is injected, covered with layers of coagulable lymph, or 
adherent. Occasionally there are sero-purulent effusions into its cavity. 

The right heart may be full or even distended with blood, the left empty; 
the pericardium containing from one to three ounces of serum. 

* In the authors MSS. was found only a memorandum, in the proper place, that this section was 
* to he written." — Ed. 



570 THE PRINCIPAL DISEASES OP THE 

3. Organs of Digestion. — The alimentary mucous membrane more seldom 
suffers in a similar, though minor degree, with the respiratory. It is found 
reddened and injected ; the glands of the ileum, both solitary and agminated, 
as well as those of the colon, being inflamed, enlarged, ulcerated, or gan- 
grenous, — changes sometimes found in other diseases and cachexias, more 
especially where the blood is known or presumed to be contaminated by the 
presence of some poison, organic or inorganic, introduced from without or 
generated within the organism. 

4. Genito-Urinary Organs. — Reddening and injection of the mucous 
membrane is the only morbid change occasionally found in these organs. 

5. Skin. — In addition to the anatomical description of the characteristic 
pustule elsewhere given by the author, it may be proper here to remark that 
it varies in form according to the locality on which it is developed, being 
more prominent, or umbilicated, or depressed in the centre, in most situa- 
tions ; but, on the face, palmar surface of the hand, and soles of the feet, it 
is not umbilicated, and is flat, or but little raised above the surface, least so 
in the latter situation. 

6. With regard to the extension of the cutaneous pustulation to the 
mucous membranes, authorities are at issue. It seems highly improbable 
that true variolous pustules should be found in such a situation, unless the 
patient had died at the commencement of the suppurative stage ; and if we 
consider the anatomical differences presented by skin and mucous mem- 
brane, — the thin and soft epithelium of the one, and the hard, resisting, 
almost horny epidermis of the other, — together with the striking varieties 
in form and development impressed upon the pustules by differences in the 
structure of those portions of the outer covering of the body on which they 
are seated, we are prepared to meet with difficulties in deciding this point. 
Moreover, it will be conceded that a thorough practical knowledge of the 
changes induced by disease in the muciparous glands of the alimentary 
canal, causing them to present a quasi-pustular appearance, though pos- 
sessed by very few, is yet absolutely necessary to a judgment on this vexed 
question. On the whole, it may be most proper to state that the occur- 
rence of variolous pustulation on the mucous membranes is probable, but 
requires further competent observation to establish it as a fact.] 



SECTION IV. 

TREATMENT. 

"When an individual who is liable to small-pox has been exposed to its 
contagion, he should lessen his diet, and reduce still further the excitement 
of his system by moderate purging. This is the extent of what he can do, 
not to prevent the disease, but to diminish its violence. When the initia- 
tory fever supervenes, if its cold or forming stage should be prolonged, to 



INTERIOR VALLEY OF NORTH AMERICA. 571 

which his anxieties of mind or the debility induced by an excess of prepara- 
tion may contribute, hot and stimulating baths and gently exciting drinks 
should be employed. The reaction being established, the treatment should 
be antiphlogistic; and comprise bleeding, purging, abstinence, diluents 
and cool air. As its object, however, is not to arrest but moderate the dis- 
ease, it will seldom happen that more than a single venesection and one or 
two cathartics will be proper; and in many cases the lancet may be omitted 
altogether. If the headache be intense, leeches to the temples, or cups to 
the nucha will be proper, and the same application will do good if the gas- 
tric irritability should be excessive. If the powers of the system should 
be too much reduced by over-officious depletion, the eruptive stage will not 
be properly formed; as on the other hand its extent may be inordinately 
increased by a hot and stimulating regimen. Thus both extremes are to be 
avoided. 

"When it begins to appear, washing the face and eyes with cold or subte- 
pid water, taking care not to expose the whole surface of the body so as to 
chill it, may limit the eruption on those parts, and protect the eyes from 
subsequent inflammation. To the same end, a bright light should be ex- 
cluded, but in doing this care should be taken not to shut out the fresh air. 
If great nervous irritation, manifested by morbid vigilance, restlessness, and 
a pulse deficient in energy, should be present, before, at the access, or during 
the progress of the eruption, a gentle opiate in connection with a moderately 
stimulating diaphoretic, will be highly beneficial. Having protected or re- 
lieved the internal organs from accidental inflammation, and contributed his 
aid to tbe due establishment of the eruption, the physician has nearly dis- 
charged his duty. The latter having appeared, the fever in all tbe milder 
cases ceases, not to reappear, the papulae go on to suppuration, and in due time 
exfoliation of the scabs is followed by convalescence. Throughout this pe- 
riod of maturation, all extremes of atmospheric temperature should be 
avoided ; the bowels of the patient should be kept open, and his diet should 
be of a moderately nutritious character. If his nights should be uncom- 
fortable and restless, mild narcotics will be admissible ; if in the period of 
scabbing, the energies of his system should flag, and his skin, losing its 
proper temperature, assume a livid hue, it will be necessary to ply him with 
ale, porter, or wine, a decoction of bark, and diet of a nutritious kind ; hav- 
ing recourse in extreme cases to carbonate of ammonia, camphor, and other 
diffusible stimuli; abating in the administration of the whole as soon as 
the symptoms for which they are given begin to cease. 

In confluent cases, the secondary fever often demands great attention. In 
some cases it is associated with inflammation of the brain, lungs, pleura, eyes, 
or skin, in the form of erysipelas. These inflammations must be met with 
leeching, cupping, or moderate venesection ; purging, saline diuretics, and 
opium with diaphoretics and calomel at night. In all, tepid fomentations 
will do much good. In the greater number of cases, however, the secondary 



572 THE PRINCIPAL DISEASES OF THE 

fever is accompanied by signs of debility and exhaustion — assumes in fact 
a typhous character, and calls for tonics, stimulants, and nutrients. 

Of the management of the pustules but little need be said. As they 
appear on the scalp and mat the hair, it should be cut off as soon as the 
true character of the disease is discovered. When they appear on the mar- 
gins of the eyelids, and threaten to invade the conjunctiva, they may be 
cauterized. If the patient has been allowed to scratch them, and the spot 
becomes raw or excoriated, it may be dressed with starch and calamine, or 
smeared with cream or a mild ointment impregnated with carbonate of lead. 
When the quantity of pus is very great, it may be absorbed by starch and 
Peruvian bark, or powdered charcoal, or prepared chalk. When the affection 
of the fauces is considerable, mopping them with a solution of chloride of 
sodium, an infusion of capsicum, or an acidulated decoction of bark will 
give relief. 

After the scabs have been thrown off, the warm bath is of service; and for 
some time the patient should guard against exposure to a cold and damp 
atmosphere, which might repress the cutaneous circulation, and originate 
internal congestion. 



CHAPTER II. 

COW-POX— VACCINIA— VARIOLA VACCINA. 



SECTION I. 

I. HISTORY AND VALUE AS A PROPHYLACTIC OF SMALL-POX. 

I AM not aware that the vesiculo-pustular disease of the teat of the cow, 
from which Dr. Jenner obtained lymph for vaccination, has yet been ob- 
served, as an endemic of our Valley ; nor do I know of any instance in which 
the cow, having taken small-pox from the human subject, has given back 
the more benign vaccine virus. Hence that which has been used by us 
from North to South, has been derived from the Atlantic States, into which it 
had been brought from England. Its introduction into the West, was early in 
the year 1802, when vaccination began in Cincinnati and other towns of the 
Valley of the Ohio, in Western Pennsylvania, Western Virginia, Ohio, Ken- 
tucky, and Tennessee. The practice of vaccination has been coextensive 
with the spread of population between the Lakes and the Gulf; but while 
every new community has enjoyed its advantages, it has by no means been 
universal in any. Several causes have contributed to this failure, which it 
may not be unprofitable briefly to enumerate. 1. The remote and insulated 
condition of new communities in a wilderness, at once protecting them from 
invasions of small-pox, and depriving them of the requisite information as 



INTERIOR VALLEY OF NORTH AMERICA. 573 

to the preventive efficacy of vaccination. 2. The difficulty, which for the 
first twenty-five years, our physicians had to encounter, in providing them- 
selves with vaccine virus. In a sparse population continued vaccination 
could not be maintained, and before the discovery that the vaccine scab 
might be employed, the infection brought from a distance was very often 
effete. 3. The objection made by many to adequate charges by their phy- 
sicians ; and then a fatal indifference about that which was offered to them 
gratuitously, or but for a nominal compensation, merely because it was so 
offered to them. 4. As a consequence of all this, ultimate apathy in many 
physicians towards the practice ; want of care as to the quality of the 
lymph employed, and neglect to observe its effects, — numerous individuals 
never being revisited after the operation was performed. 5. An unworthy 
manifestation of personal dread of small-pox, by many physicians who had 
been vaccinated before, but especially since the first appearance of varioloid 
among us. 6. The absurd reasoning of many persons, that as cow-pox is 
not an infallible protection from small-pox, it is not worth while to resort 
to it. 

To these, and other less general causes, we owe it that a large but un- 
ascertained proportion of our population have never been vaccinated, and 
the relative number is not likely to be diminished ; for the occurrence of 
varioloid in later years, has, I fear, diminished the practice of vaccination 
in a greater ratio than the abatement of some other retarding causes might 
have promoted it. Under these circumstances, the question arises whether 
anything can be done to render the practice more general ? I can think of 
no influence which could be brought to bear on the people in a direct man- 
ner to this end, but, perhaps, if a strong effort were made on our state 
legislatures, they might be prompted to certain enactments fitted to impart 
a general impulse to the practice. 

1. As the militia are enrolled for the common defence, and as the small- 
pox introduced into an army liable to it, might at any time defeat the object 
for which it was taken into the field, it would seem to be not inconsistent 
with the principles of constitutional liberty, to require that all should be 
vaccinated. 2. Wherever public schools are established, it might be re- 
quired as a condition to the admission of children of both sexes, that they 
shall have been vaccinated. 3. All charters for academies, colleges, and 
universities, might require the same condition. 4. To aid in the execution 
of such laws, it might be enacted, that the guardians of the poor, and the 
governors of all hospitals authorized by the states, should cause gratuitous 
vaccination to be performed in all cases where, through poverty, it might be 
demanded. 

It may be asked to what good purpose would these regulations tend, if 
individuals are liable to small-pox after vaccination? I answer, that since 
the discovery of the vaccine disease, small-pox remains a scourge of society, 
not because the former is a fallible preventive, but because it is not univer- 



574 THE PRINCIPAL DISEASES OF THE 

sally employed. If all who are born were carefully vaccinated, small-pox 
would probably disappear, and certainly lose its mortal character, a result 
that should satisfy us. In support of the former part of this proposition, I 
may refer to the epidemic of Marseilles, France, in 1828. Of the unvacci- 
nated, one half were seized with small-pox, while of the vaccinated, a 
fifteenth only were attacked. Now it is scarcely possible that any conta- 
gious disease would spread through the atmosphere, in a community of 
which only one person in fifteen was liable to it. It is in fact on the unvac- 
cinated, that the responsibility rests of keeping alive and in mortal activity 
this frightful epidemic. But suppose this conclusion too broad, and that 
small-pox would survive universal vaccination, the latter clause of our pro- 
position is unquestionable, for what would small-pox then be ? One of our 
mild and least dreaded eruptive fevers, scarcely rising on the scale of mor- 
tality above varicella or urticaria. While the deaths at Marseilles from 
small-pox in the unvaccinated were one out of four cases ; they were but one 
out of a hundred among the vaccinated. Again, in Philadelphia, in 1823-4, 
Drs. Bell and Mitchell,* saw of the former class, 85 deaths, out of 155, more 
than half; while of 64 of the latter class, but one died. And again, in 
1818-19, Dr. Thomson, of Scotland, saw 50 out of 205, unvaccinated 
patients die, while of 310 who had been vaccinated, but one died ! In the 
small-pox hospital of London, 1838,f out if 396 cases occurring among the 
unvaccinated, there were 143 deaths; and of 298 vaccinated, 21 died. 

If we take the average which these statements afford, we find that of 4756 
unvaccinated, 1278, or 1 in 3-72 died; while of 2669 vaccinated, but 43, or 
1 in 62 were lost. Universal vaccination would then give us a disease, 
which destroys but 1-61 per cent, for one which kills 26-8 per cent, of its 
subjects. Now at Marseilles, out of 30,000 vaccinated persons, 2000 ex- 
perienced small-pox, and if they had died at the rate of 1*61 per cent., 
which they did not, it would have given but 48-3 deaths for the 30,000, or 
1 in 622. Such is the mortality of small-pox among the vaccinated. Most 
assuredly then, a disease which destroys less than a six-hundredth part of 
the population is not greatly to be dreaded, and such, as far as we can now 
judge, might small-pox be rendered by universal vaccination, should that 
disease then continue to prevail, which I think by no means probable. 
There are some disheartened by the occasional occurrence of small-pox in 
the vaccinated, who would return to inoculation, as affording a more infal- 
lible protection ; but against this backsliding there are insuperable objec- 
tions, for — 1st. Inoculation, although a better protection than vaccination, 
is not infallible, and the mortality among those who subsequently contract 
small-pox, is greater than that among the vaccinated. 2d. Small-pox from 
inoculation, is on the whole a more fatal disease than small-pox following 
vaccination. 3d. The practice of inoculation tends to keep alive in the 

* North American Med. and Surg. Jour. vol. ii. p. 249. 
t EMotson's Prin. & Prac. p. 436. 



INTERIOR VALLEY OF NORTH AMERICA. 575 

world, the disease which it is the object of vaccination to annihilate by de- 
priving it of subjects. 

II. MANAGEMENT. 

Subjects. — When small-pox is epidemic the youngest infants may be 
vaccinated ; but notwithstanding the disease may pass regularly through 
its stages, it will be proper to repeat the operation at a future time, as im- 
pressions on their systems at that early period may not remain unimpaired. 
Under ordinary circumstances the operation may be postponed to the second 
or third year. Persons of every age are susceptible. In the first year of 
the introduction of the disease into Cincinnati, I saw a lady ninety-eight 
or one hundred years old go regularly through it. In general it is more 
severe in the aged than in the young; and slower in its development. 
Those who are in bad health, or affected with any chronic disease of the 
skin, should not be vaccinated unless small-pox be prevalent ; and all such 
should be subjected to re-vaccination when in better health. Some indi- 
viduals, from idiosyncrasy, at every period of life prove to be insusceptible. 
When this is the case with adults, our efforts may cease after a few trials 
with virus fresh from the arms of different patients, inserted in different 
parts of the body, in various seasons of the year j but in the case of chil- 
dren, the operation must be repeated through a longer period in the hope 
that age may have rendered them susceptible. It might be supposed that 
those who are insusceptible to the vaccine, would be equally so to the vario- 
lous infection, but we must recollect that a violent epidemic small-pox has 
often affected a second time those who had once experienced that disease, 
and also reached those who had often lived through mild epidemics without 
having had an attack ; showing that the system may be acted on by a con- 
centrated or highly virulent infection, when a more dilute or feeble one 
fails, and suggesting therefore that an individual might resist the action of 
the vaccine and still be susceptible to the variolous contagion. 

Vaccine Matter. — This should always be taken from the arm of a 
healthy subject, especially of one free from developed scrofula, from secon- 
dary syphilis, itch, tetter, lepra, and all other cutaneous affections. Inocu- 
lation directly from the arm should be preferred to the use of the scab, and 
the earlier the vesicle is opened the more active is the virus ; but none 
should be taken from a vesicle that has been ruptured by violence, or from 
which matter has been drawn the day before, as even the puncture of the 
lancet may have modified the true vaccine action, and changed the character 
of the secretion. When therefore several patients are to be vaccinated 
from the same vesicle, they should be assembled at the same time and place. 
When a scab is used it should be solid, tenacious, of regular and circular 
form, and of the well-known mahogany hue. 

Operation. — As the great vascularity of the skins of children often 



576 THE PRINCIPAL DISEASES OF THE 

causes a flow of blood that washes away the virus and renders a repetition 
of the operation necessary, the part into which it is inserted should be so 
compressed between the thumb and finger, as to squeeze out the blood, and 
should be held in that condition until the virus has had time to diffuse 
itself on the surfaces of the puncture. I am not prepared to believe that 
more than one insertion is necessary to the full preventive effect of the dis- 
ease ; but as one puncture might fail and another succeed, as one might be 
injured by external violence, or opened to supply lymph, and as it is desi- 
rable that the one on whose protection we rely, should pass through all its 
stages untouched, it will be proper to make two or more, which in reference 
to accidents had better be on different limbs. 

Diagnosis. — A premature development of inflammation in the punc- 
tured part ; an irregular figure of the vesicle ; an areola too limited or too 
extensive ; an early turbidness of the contents of the vesicle, or its inordi- 
nate dimensions ; a want of regularity of form, coherence, and characteristic 
color in the scab ; a deep and intractable ulcer following its detachment ; 
finally a broad, smooth, and unindented eschar, should all be looked upon 
with suspicion, and if any two or more of such irregularities should be ob- 
served, re-vaccination ought to follow. 

The natural course of the disease is the same in children as in adults, 
but the successive stages generally arrive a day earlier. By the beginning 
of the third day in the former, of the fourth in the latter, a flea-bite look- 
ing spot shows itself. In two days more it exhibits the appearance of a 
flattened and indented vesicle, which regularly enlarges in circumference and 
elevation, still retaining the same form ; by the seventh or eighth the 
areola is established, and attains its maximum by the ninth or tenth, when 
the limpid fluid becomes opaque, and in adults some chilliness with flashes 
of fever, and feelings of slight indisposition occasionally manifest them- 
selves. An inflamed absorbent may now be traced on the arm in some 
cases, and the axillary ganglia will be more or less swollen. Rarely a few 
vesicles appear on other parts of the body. The disappearance of the areola 
and the formation of a mahogany-colored scab occur at the same time. 
The exfoliation of the latter takes place at no particular time, occurring as 
early as the middle or not till after the end of the third week. The spot 
from which it is detached should present and retain a pitted or faveolous 
appearance, corresponding with the radiating cells of the vesicle. 

Test. — Our physicians are not accustomed to resort to the test of genu- 
ineness proposed by Mr. Bryce, of England, although easily practised and 
generally admitted to be valid. He advises in four or five days after the 
first operation, to vaccinate again. If the former operation is affecting the 
constitution, the latter will advance with such rapidity, that the two vesicles 
will arrive at maturity at the same time, but the second will be smaller than 
the first. If it should not have affected the constitution, however, the sub- 
sequent vaccination will pass through its different stages in the usual time. 



INTERIOR VALLEY OF NORTH AMERICA. 577 

Revaccination. — We have already seen that a variable proportion of the 
vaccinated are liable to small-pox. This roay be owing to several causes. 
1st. The use of spurious cow-pock matter. 2d. Accidents to the vesicle. 
3d. The presence in the skin or in the organism generally, of some morbid 
diathesis at the time of vaccination. 4th. The performance of the opera- 
tion in very early infancy. 5th. A peculiarity of constitution of the kind 
which renders certain individuals liable to second attacks of small-pox. But 
after making due allowance for these causes, of which the last is no doubt 
most efficient, we are tempted by the number of attacks of small-pox after 
vaccination, to admit the probable existence of others. These it has been 
conjectured are the two following: 1st. A deterioration in the protective 
power of the vaccine virus from having passed through many human sys- 
tems after being drawn from that of the cow, in the latter part of 
the last century. 2d. A loss, from the lapse of time, of the immunity from 
small-pox bestowed by vaccination. Both these conjectures deserve consi- 
deration. 

1. I vaccinated myself in the year 1802, and engaged in vaccinating in 
1803, with lymph, only five or at most seven years from the cow. I am 
now (1846), after the lapse of forty-four years, enabled to state that the 
phenomena and stages of the disease have undergone no change. The early 
and latter descriptions of it as found in the books are in fact identical. Now 
it seems extremely improbable that the vaccine disease should decline in its 
specific protecting power, without undergoing a change in its symptoms. 
Nevertheless, as this conclusion may be erroneous, and as it is contrary to 
the prevailing opinion of the profession, attempts to substitute a recent for 
the old virus ought to be encouraged. These efforts seem to have been 
more successful in Europe than America. The latest acquisition, I believe, 
was by Mr. Estlin, of Bristol, England, in 1838, who made it in a dairy 
near that city. It has been found more energetic than that in common 
use. I do not know that it has yet been introduced among us. 

2. The opinion, that time destroys the immunity from small-pox bestowed 
by vaccination, is in all respects of deeper interest than the speculation we 
have just discussed. It is obviously impossible to decide this question 
a priori; and even experiment and observation have not led us to satisfac- 
tory conclusions. When an individual, after the lapse of a number of years, 
is seized with small-pox, the question will arise, unless he had been repeat- 
edly exposed to its contagion, whether he ever had been protected ? All 
that we know relative to the loss of immunity in early life, leads to the 
conclusion that children vaccinated in infancy are not liable to small-pox 
before the ninth or tenth year, and that but few lose their immunity till 
after the age of puberty. It is for the next twenty or twenty-five years 
from that epoch, that small-pox is most likely to attack them. After the 
thirty-fifth year, the exemption is generally perfect. This may perhaps in 
part arise from the diminished susceptibility to small-pox contagion in ad- 

vol. ii. 37 



578 THE PRINCIPAL DISEASES OP THE 

vanced life. Even throughout this period, however, individuals may become 
infected during variolous epidemic visitations of an intense character, as it 
is chiefly those which excite that disease in both the inoculated and the vac- 
cinated. If an individual have lost the immunity bestowed by vaccination, 
can it be restored by repeating the operation ? Experience seems to have 
answered this question in the affirmative. The symptoms and progress of 
the second disease appear not to differ from those of the first, except as far 
as a difference in age is concerned. The practical precept relative to revac- 
cination may be thus stated. 

If the child have undergone the operation in infancy, no fears need be 
entertained for the next seven or eight years, that is, till it is nine or ten ; 
but if at the latter period a variolous epidemic should arise, it should be 
revaccinated; if not, the operation should be postponed till it has passed 
the age of puberty, when it should be resorted to as a means of restoring an 
immunity which may, or may not have been lost. Should this revaccina- 
tion take effect, and proceed with regularity, no other need ever be em- 
ployed; but should it fail, a third operation should be performed when the 
period of adolescence is completed, that is, in the twenty-first or twenty- 
second year, after which it need not be repeated.* 

Theory of Variolous Exemption. — The whole profession is familiar with 
the fact that a salivation may be repeatedly excited, and that, too, with 
increasing facility; each invasion of mercurial disease increasing the sus- 
ceptibility of the system to the action of the medicine. On the contrary, 
opium and other narcotics rapidly destroy such susceptibility. Syphilis and 
psora, depending on morbid animal poisons, may be reproduced, at least 
without any diminution of facility. An attack of small-pox, on the other 
hand, in general renders the system insusceptible to the poisons of that 
malady for the future. These remarkable differences in the effects of dif- 
ferent active agents on our vital susceptibilities, are inexplicable mysteries, 
which, in the present state of our knowledge, must be taken as ultimate 
facts. When we contemplate the violent perturbation of the whole system, 
and the extensive lesions of the skin in a case of small-pox, we seem to 
behold anatomical and physiological changes sufficient to explain the future 
immunity from that disease, and although this be a fallacy (since extensive 
disruptions of the organism in other forms of disease do not create exemp- 
tion), still the mind is contented to rest upon it. But vaccination is not 
followed by these perturbations of the constitution, or anatomical derange- 
ments of the skin ; in numerous instances not the slightest indisposition 
follows, and all the manifestations of disease are confined to a few square 
inches of the surface of a limb, and yet the constitution has undergone a 
change which renders it invulnerable in the main, not only to the virus 
which produced the effect, but to that of small-pox. It is impossible to 

* Dr. Gregory, in Lib. of Med. vol. i. Eep. of the Accad. of Scien. of France, 1S15. 



INTERIOR VALLEY OF NORTH AMERICA. 579 

admit that this change is anatomical ; and its production, independently of 
any physiological disturbance of which the observer is cognizant, or the 
patient conscious, is well fitted to excite our wonder and humble our scien- 
tific pretensions. It shows that there are depths in the living body where 
the sounding line of the physiologist has never yet reached bottom, — vital 
laws of which no interpreter has yet appeared. The hypothesis of Liebig, 
that the virus acts as a ferment upon some material in the blood, and 
destroys it, so that in a subsequent application of the same virus no effect 
can be produced, must be regarded as a most improbable fancy; for, in the 
first place, it is inconceivable that such a fermentation should not be at- 
tended with some degree of constitutional disturbance j in the second, the 
very existence of such an element is conjectural; in the third, if it exist, it 
is a normal element of the blood, and its consumption could not fail to be 
followed by injury to the economy, seeing that it was created for some end — 
had some part to perform in the functions of that economy. Thus we are 
driven, I think, to regard the nervous system as the tissue on which the 
poison exerts itself, and compelled to rest on some mysterious and transcen- 
dental change in the innervation, as the immediate cause of the immunity. 



CHAPTER III. 

MODIFIED SMALL-POX, VARIOLOID.— RELATIONS TO VARIOLA AND 

VACCINA. 

When the eruptive disease to which this name is applied first began, by 
its epidemic prevalence in 1817 or '18 on to 1823, to fix the attention of 
the profession in Europe and the United States, three opinions of its cha- 
racter were entertained : one that it was varicella of unusual violence, 
another that it was a new eruptive fever, a third that it was small-pox 
occurring in persons who had been successfully inoculated or vaccinated. 
The last opinion has received the sanction of the profession, and is unques- 
tionably the correct one ; for, in the first place, exposure to small-pox will 
produce varioloid in some of those who have either had that disease or the 
cow-pox; in the second, an individual who has never had either will contract 
genuine small-pox from exposure to varioloid, or by inoculation with its 
virus ; and, lastly, the analogy of symptoms is so great as to complete the 
demonstration. 

It appears, then, that some of those who have undergone small-pox, and 
a greater number who have experienced cow-pox, remain or become liable 
to be acted upon by the variolous poison ; but that their systems have under- 
gone a change, which is the cause of a modification and decided mitigation 
of the disease produced by that poison. Hence we see that the same morbid 
animal poison (the primary source of which is unknown to us), is capable 



580 THE PRINCIPAL DISEASES OF THE 

of undergoing changes, which, in connection with modifications of constitu- 
tion effected by itself, result in three varieties of disease : variola, vaccina, 
and varioloid. The virus of the first introduced into the body of the cow, 
may be followed by the production of a pus, which inserted into the body 
of a person who has never had small-pox, will generate the second ; and 
the individual subsequently exposed to the contagion of the first, will be 
attacked with the third. It is worthy of remark, that while a greater pro- 
portion of those who have had cow-pox than of those who have had small- 
pox are liable to varioloid, that disease is on the whole more dangerous in 
the latter than in the former class of patients, — a fact which I think could 
not have been anticipated. "Varioloid, although long known sporadically as 
secondary small-pox, could not have had an epidemic existence but* for 
vaccination, for the reason that the number of the inoculated who are liable 
to second attacks is so small, that the disease would be confined within too 
narrow limits to constitute an epidemic. Hence, the first that appeared 
was about twenty years after vaccination commenced, when the number of 
its subjects had become sufficiently numerous to admit of an epidemic pre- 
valence. 

SYMPTOMS AND TREATMENT. 

Symptoms. — In its access and course, the eruptive fever of varioloid is not 
distinguishable from that of inoculated small-pox; and in many cases it is 
not more intense than in varicella. It scarcely ever survives the first day 
of the efflorescence, and never reappears as secondary fever. The efflorescence 
occurs rather earlier than later than it does in small-pox; and although the 
papulae are sometimes so numerous as to constitute a rash, a comparatively 
small number go on to maturity. Those which do, advance more rapidly 
than in small-pox, but very unequally among themselves. Many of them 
indeed prove abortions, and after reaching the point at which they might 
assume a vesicular appearance, begin to decline ; thus we see in the same 
regions pimples without a fluid, vesicles containing lymph, and others the 
contents of which have become opaque, peculiarities which I have been 
accustomed to regard as characteristic of this disease. In general, by the 
fifth or seventh day from the beginning of the fever, the pustules have run 
their course — those which failed have entirely receded, aud those which came 
to maturity have begun to scab. They present the cupped summits of the 
true variolous pustule, but are not followed by the deep and indented scars 
of that disease. The dangerous internal congestions and cellular inflamma- 
tions, sloughings, and other severe local affections attendant on natural 
small-pox, seldom or never occur, and the convalescence of the patient is 
generally rapid and favorable. If there be cases which are more violent 
than these, there are others more mild. The latter approach so nearly to 
varicella as to be readily confounded with that disease ; the former make 

* Ceely, in the Library of Med. vol. iii. 



INTERIOR VALLEY OF NORTH AMERICA. 581 

an equal approach to natural small-pox ; and some of them doubtless are 
that disease,. although classed with varioloid, for all vaccinated persons do 
not have cow-pox. 

Of the low mortality of the varioloid affection, I have already spoken, and 
when we take it into connection with the assemblage of mitigated symptoms 
here described, every candid mind must admit, that if all vaccinated per- 
sons were liable to it, the discovery of the immortal Jenner would still be 
a precious boon to the human race. 

Treatment.— Little or nothing need be said under this head ; as the 
treatment adapted to mild small-pox, is the most that can be required in 
varioloid. Indeed, many cases do not require the interference of art ; and 
in all such, it is the duty of the physician to stand as a mere spectator, that 
the community may have evidence, founded on their own observation, that 
when small-pox does follow successful vaccination, it is not a disease to be 
dreaded. In proportion as they can be brought to distinguish between the 
suffering and danger of natural and modified small-pox, they will be inclined 
to resort to vaccination. 

MISCELLANEOUS FACTS AND OBSERVATIONS. 

Epizootic Small-pox. — Since it has been proven that vaccine infection is 
not specifically distinct from variolous, and that the cow inoculated with the 
latter generates the former, she may be said to be liable to small-pox. This 
suggests the question whether she originally contracted the disease from 
the human race, or from the same unknown source with ourselves ? Analogy 
would lead us to suppose that the malady might have begun with her, as 
hydrophobia with the dog, and glanders with the horse, both of which are 
commuuicable to man. The accidental cow-pox on the hands of dairymen, 
which first attracted the attention of Dr. Jenner, was of a similar kind ; but 
the intensity of natural small-pox does not permit us to regard it as of 
epizootic origin, that is, from the same fountain with the benign vaccine 
disease; while its occasional epidemic and malignant character seems to 
mark it as originating de novo, from some unknown and inscrutable agency. 
The same influence may have started it in the cow, or she may have received 
it from man. If the latter, the difficulty of propagating it to her is great, 
as most of the multiplied efforts made for that purpose have proved unsuc- 
cessful. In 1803, as hundreds have done since, I inoculated the teats of 
cows with small-pox matter fresh from the pustule, but it produced no effect. 
To what shall we ascribe these failures ? May it not be that the animal, 
like ourselves, is subject to the disease but once, and that perchance those 
inoculated had already passed through an attack? Considered as an 
endemic of neat cattle, it may invade them much oftener than we are aware, 
not being recognized by us except when pustules appear on the teats. 

Vaccine Infection from the Cow. — In the winter of 1845-6, a dairyman, 
of the neighborhood of Cincinnati, brought to Dr. Langdon some scabs 



582 THE PRINCIPAL DISEASES OF THE 

taken from the udder of one of his cows, telling him that others of the herd 
had labored under the same pustular disease. The Doctor observed that 
they were inclined to an oval shape, were deeply indented on the inner sur- 
face, and of a lighter color, less thickness, and greater roughness, than the 
vaccine scab from the human arm. Soon after receiving these scabs, the 
Doctor met with an unvaccinated family, which included seven children, 
lately from the country. Two of them, at the time, were out at service, 
but he vaccinated the other five. They all had the cow-pox. Their arms 
were rather more inflamed than usual, the axillary ganglia swelled, and 
they experienced more than the common degree of fever. The scabs which 
formed were the most beautiful and characteristic he had ever seen. He 
vaccinated from some of them, and distributed the rest among the physicians 
of the city. They produced the genuine disease, but it was not more intense 
than common. Soon after the family first vaccinated had passed through 
the disease, one of the children that had been at work from home, and was, 
therefore, not vaccinated with the rest, was seized with an acute fever, 
which, in three days, ceased, with the appearance of an eruption, which 
proved to be variolous, and passed regularly through all the stages of small- 
pox, which disease was at that time prevailing to some extent in the city. 
The recently vaccinated children continued in the same room with this 
patient, and all escaped the disease; but another person living in the same 
house contracted it. 

Small-pox Propagated to the Cow without Inoculation. — The following 
fact was lately communicated to me by Dr. John F. Henry, of Burlington, 
Iowa : — 

" Burlington, Jan. 20, 1846. 

" Dear Sir : — I enclose you a portion of a scab obtained from a yearling 
calf nine miles west of this town. The history of the case is this : In the 
early part of December, some six or eight members of the family had the 
small-pox in the natural way. They had it badly, and one or two died. 
They lived in a cabin, and this calf fed about the door. When the people 
recovered, their clothes were washed, and the suds put outside, where, it is 
said, this calf drank of them. It is supposed that a cow also partook of the 
same delectable beverage. The animals were soon observed to be puny and 
moping, refusing their food, &c, and in three days an eruption appeared 
upon both, but especially the calf, which the family said l exactly resembled 
small-pox/ As the family had just gone through the disease, it may be 
presumed they could form a very accurate opinion on this subject. 

"I did not hear of this singular case until Saturday evening last. On 
Sunday, 19th, I rode out in company with Drs. Ransom and Lowe to examine 
the animals, and gather up such information as I could. We found the 
calf with marks in various parts of the skin, especially about the mouth 
and nares, shoulder, udder, and legs. Some of them resembled the tender 



INTERIOR VALLEY OF NORTH AMERICA. 583 

cicatrices which might be supposed to result from a variolous pustule. 
Others had still a scab on them; but whether primary or secondary I could 
not tell. In all the hair was denuded, and where the scab yet remained the 
true skin was elevated the one-twelfth of an inch. I carefully removed as 
much of the scabs as I could, and the portion now sent to you is some of 
the most promising. 

" I have used it in one case, and intend trying it in others. Dr. Black, 
to whom I gave a portion of the scab, has used it in some twenty cases. 
The result is, of course, not yet known ; but at the proper time I will com- 
municate it to you. Having tried unsuccessfully, in Illinois, to infect a 
cow with variolous matter, I look on this infection in the natural way as a 
rare case, which deserves to be recorded and preserved. Should the scabs 
we have obtained produce in human beings the mitigated disease, with 
strong prophylactic powers, it will be eminently worthy of the attention of 
the profession, and I flatter myself may constitute an era in vaccination. 

"I am, dear sir, 

"Your friend, 

"John F. Henry." 

Small-pox Eighteen Days after Exposure. — As a fortnight is given in 
our standard works as a sort of maximum for the term of incubation, I am 
induced to state the following fact, communicated to me by a respectable 
medical gentleman of Ohio. 

As an object of curiosity, he visited a man on the seventh day of the 
eruption in confluent small-pox, and spent an hour in his room, which was 
large and well ventilated. He was careful to avoid bringing his clothes in 
contact with the body or bed of the patient, and after leaving the house 
washed his hands in a brook. On his way back to the town in which he 
resided, he stopped and dined at the house of a friend and patient. A 
daughter of the gentleman, fourteen years old, sat opposite to him at the 
table, and was in the room a few minutes before and after dinner. She had 
a sort of erysipelatous inflammation on her face, which he was requested to 
examine, and over which he passed one of his fingers. This was on the 
25th of April, and on the 13th of May she was seized with fever, which 
was followed by a variolous eruption on the 15th. I should not have 
thought this fact worth publication, but as a caution to physicians in refe- 
rence to the spread of the disease by their professional visits. 

Vaccination after Inoculation taking effect first. — In the year 1843, 
Dr. Fearn, of Mobile,* saw five negroes, ill with small-pox, taken to a plan- 
tation where there were many others who were unprotected. The huts of 
the whole were near together. He immediately vaccinated the unprotected; 
but not having confidence in the activity of his virus, on the fourth day 
afterwards he inoculated the whole with pus from the arm of one of the 

* MS. Mem. 



584 THE PRINCIPAL DISEASES OF THE 

patients. The next day, having received fresh vaccine virus from New- 
Orleans, he immediately vaccinated the same individuals. The first vacci- 
nation, with what proved to be effete virus, produced no effect; the second 
produced cow-pox at the regular time and with the ordinary symptoms. 
After the disease had run its course, the variolous poison began to show its 
influence. A pustule formed on the arm of each, but produced neither con- 
stitutional disorder nor eruption. None of the patients contracted " natural" 
small-pox. 

Vaccination during Continued Exposure to Variolous Infection. — Dr. 
Crookshank, of Harrison, Ohio,* was called to a man with distinct small- 
pox, whose children, occupying the same room with him, were unprotected. 
It was not till four days after the eruption had made its appearance that the 
Doctor succeeded in obtaining cow-pox matter, when he immediately vac- 
cinated each of the children in several places. It took effect, and came to 
maturity between the sixth and ninth day in all except a little girl, who 
labored under a herpetic eruption of three or four years' standing, and who, 
moreover, escaped the small-pox, although she remained constantly at home. 
Each of the others, notwithstanding the development of cow-pox, sickened, 
but not at the same time, and had distinct variolous pustules, coming to 
maturity nearly at the same time with the vaccine, which assumed a puru- 
lent appearance identical with the variolous. Those in which the vaccine 
vesicle was furthest advanced before the appearance of the variolous, had the 
latter in a milder form than the others. The youngest child, an infant, 
died ) but when the variolous fever set in, the vaccine vesicles were but 
beginning to show themselves, and as its mother was ill at the time, it was 
necessarily neglected. 



CHAPTER IV. 

VARICELLA OR CHICKEN-POX. 

Chicken-pox : Varicella. — This little vesicular disease has acquired 
new importance in modern times from being confounded with varioloid. 
They who have done this must have compared varioloid with itself, after 
having applied to some of the cases the epithet varicella. They could see 
but one epidemic, because in fact there was but one under their observation 
at the time. The existence of a distinct eruptive disease which has received 
the name of varicella, is, however, a reality. It attacks equally the vacci- 
nated and unvaccinated ; does not prevent the subsequent occurrence of 
either small-pox or varioloid, and although apparently contagious, cannot 
be propagated by inoculation. Its symptoms afford equal aids to a diffe- 
rential and comparative diagnosis. The eruptive fever, generally slight, is 

* West. Med. Gaz. vol. ii. p. 167. 



INTERIOR VALLEY OF NORTH AMERICA. 585 

sometimes unobserved. In this respect it even falls below the mildest 
varioloid. Some malaise or indisposition, however, is always present. 
When fever occurs, the eruption generally appears on the second day. Its 
first appearance is on the upper part of the trunk of the body, or simulta- 
neously on that part and the limbs ; all of which are less affected than the 
face : another distinctive mark between it and varioloid. It presents con- 
siderable variety. When at the beginning it is somwhat papular, a part of 
the papulae soon becoming vesicular, it has received the popular appellation 
of chicken-pox. When vesicular from the start, it is called by the people 
swine-pox. The vesicles are almost always hemispherical, or bluntly conoidal, 
very rarely indented: another point of separation from varioloid. Yery 
little basilar or surrounding inflammation attends the vesiculation, the 
lymph soon becomes more or less opaque, and frail light-colored scabs are 
formed, which, on falling off, leave few or no eschars. When in St. Charles, 
Mo., in the month of July, 1844, while in Dr. Wyman's office, a woman 
brought her child (in the arms), for advice in a disease of this kind. The 
upper part of its body and arms were covered with isolated semi-globular 
vesicles or blebs, some of which had a diameter equal to that of a dime, 
but the majority were smaller. A few were surrounded at the base with a 
narrow areola. According to the statement of the mother, they attaiued 
their full dimensions in a single day or even a few hours. Some were filled 
with transparent lymph, in others it was opaque, and others presented light- 
colored brittle and ragged scabs. On the same day, I saw another child, 
three years old, running about the house, with an eruption of the same kind, 
chiefly affecting the chest and neck, on some parts of which they were almost 
confluent. The parents assured me that they were " blisters" from the be- 
ginning, and attained their full size in a few hours. Some were very small, 
and others converted into scabs of the kind just described. The lower half, 
or a segment of several of them (the child being on its feet), was filled with 
an opaque fluid, while the upper was still transparent. This seems to indi- 
cate that the loss of transparency was not owing to a spontaneous change in 
the serum of the vesicle, but to the secretion and infiltration into it of a 
purulent fluid which gravitated to the bottom. The child did not appear 
to have any constitutional illness. Dr. Twyman and other physicians of 
the place, informed me that they had at that time many other cases of the 
same kind ; in short, it was an epidemic " swine-pox/' 

Varioloid could by no possibility be confounded with such a disease as this, 
though it might be with the more papular varieties of varicella, especially 
when attended with much eruptive fever. Is is the duty of a physician not 
to fall into this mistake of diagnosis, and whenever he doubts, it is safer for 
society to regard the disease (practically) as varioloid. 

I have not seen any serious internal complications with varicella, nor at 
any time a fatal case. Such, however, have been reported, occurring doubt- 
less from previous tendency to disease in the brain or lungs. Such cases 



586 THE PRINCIPAL DISEASES OF THE 

would of course require the treatment appropriate to the local affection; but 
in general little or nothing is required to be done for the uncomplicated 
varicella. 



CHAPTER V. 

MEASLES— KUBEOLA. 

Geography. — This eruptive fever prevails from the Lakes to the shores 
of the Gulf, affecting the inhabitants of both town and country. The result 
of my inquiries is, that the disease is more frequently epidemic in the higher 
than the lower latitudes, and oftener fatal; but these conclusions may be 
modified by additional facts. In the larger towns, the disease is more fre- 
quently epidemic than in the villages and country. Some places seem to 
have escaped altogether, and I have met with many physicians, of several 
years' practice, especially in the South, who had never seen a case. 

Chronology. — This disease dates from the first settlement of the interior. 
It was wont to occur in the infant and insulated communities of Kentucky 
and Ohio, in the latter part of the last century, introduced by emigrants, or 
produced by a cause generated among them, de novo. From the tardy 
travel of immigrants at that early period, and the wide separation from each 
other of the " stations," as the first settlements were called, the presumption 
would be in favor of the latter. It does not appear that this malady makes 
its visitations at stated periods, and they are generally more frequent as 
the town, village, or city is more populous. Dr. Hildreth* has observed 
Marietta to be visited at periods of eight or ten years. The visitations of 
Cincinnati, Louisville, and St. Louis have been more frequent. Although 
not confined to the first half of the year, this disease generally commences 
in winter, and being most common in spring, disappears in the course of the 
summer. In 1842, it prevailed to a great extent in many of the north- 
eastern towns of Ohio ; beginning, as Dr. Estel informed me, at Canton, on 
the first of January, and in Talmadge, a little further north, according to Dr. 
Wright, a month later. When I visited those places, in September, it had 
ceased. In the months of April and May, 1844, I found it extensively 
prevalent in the maritime parts of Alabama and Louisiana. The length of 
time that measles will linger in a village is in some cases remarkable. Even 
on a plantation, Dr. Drish, of Alabama, has seen it continue for a year. 

Subjects. — Measles affect the white, black, and red population in an 
equal degree ; and although children are the most obnoxious, in violent 
epidemics, persons of every age are seized. In the season last referred to, 
with Dr. Cotman, of Donaldsonville, on the Wade Hampton sugar plantation, 
near that town, I saw several aged negroes, one of whom appeared to be at 

* Report to the Med. Conv. of Ohio, May, 1839. 



INTERIOR VALLEY OF NORTH AMERICA. 587 

least eighty, affected with the disease, in the midst of a great number of 
children. It is impossible, I suppose, to decide with any certainty whether 
such cases are first or second attacks ; in either case they may be regarded 
as indicating great energy in the cause. 

Propagation. — While every physician has met with cases of measles 
which he could not trace up to others, either directly or indirectly, the gene- 
ral propagation of the disease by infection may be received as an established 
fact. The exceptions in the present state of our knowledge, like those pre- 
sented by scarlatina, mumps, and pertussis, are mysterious and perplexing. 
Whether the exhalations from the body of a patient before the appearance 
of the efflorescence will communicate the disease, is still an open ques- 
tion, the negative of which ought not to be assumed. Inoculation has to a 
limited extent been practised in measles. Blood drawn from the efflorescing 
skin has raised the disease in others ; and the serum from minute vesicles 
occasionally found on the same surface has likewise been successfully em- 
ployed, but appears to be less certain. I do not know that the thin sero- 
mucous secretion from the ScliDeiderian membrane has been tried. [Dr. 
Katona employed a drop of the tears, as well as the vesicular fluid and blood. 
The inoculation failed in seven per cent, of the cases. In a very malignant 
epidemic occurring in Hungary in 1841-2, of upwards of one thousand 
persons successfully inoculated by Dr. Katona, not one died.] The uncer- 
tainty of these inoculations, and the little difference between the disease 
raised in that way, and the ordinary mode of propagation, are likely to pre- 
vent inoculation from becoming general. The period of incubation in 
measles is said by those who have taken pains to collect and compare au- 
thorities, to range from six to sixteen days,* but these are palpable ex- 
tremes, and the more common range is from the ninth to the twelfth day. 
In Tuscaloosa, a young man came into Dr. Haywood's office, where there 
happened to be a child with measles. Nine days afterwards, he was taken 
down with the disease, which spread from him through the neighborhood, 
previously exempt. The period of incubation seems to be unattended with 
any kind of indisposition, and I do not know any required treatment; 
though, from the character of the disease, it would undoubtedly be proper 
to avoid contracting a catarrh. 

Symptoms. — These are substantially the same, both in the Xorth and 
South j and so conformable to the descriptions found in European books, 
as to show that localities and modifications of society exert but little, if any, 
influence on the aspect of the disease, an evidence in favor of the theory of 
exclusive contagious propagation. 

At its onset, measles may be characterized as an inflammatory catarrhal 
fever, ushered in by an irregular and protracted chill. The local symptoms, 
however, are those of coryza rather than pulmonary catarrh ; such as sneez- 
ing, a sense of fulness in the maxillary and frontal sinuses, congestions of 

* Library of Med. vol. iii. 



588 THE PRINCIPAL DISEASES OF THE 

the conjunctivae, as of the Schneiderian membrane, and a profuse serous 
secretion from the whole. The glottis and larynx next become the seat of 
irritation, and a hoarse cough is provoked ; lastly, the bronchial tubes be- 
come involved, and a pectoral cough commences, and sometimes becomes 
harassing and protracted — all of which is in the order in which many 
catarrhs and influenzas are developed. The cases described in the books, 
of measles without this affection of the aerial mucous membrane, I have 
not met with, nor have such been mentioned to me. It is, I believe, the 
opinion of those who have described them, that they do not protect against 
a second attack. The eruptive fever in this disease, is not, in general, very 
acute and inflammatory, and the pain of the back, limbs, and head, is less 
than in small-pox. The heat of the skin, sometimes considerable, is seldom 
intense. A comatose state in children occasionally attends on this stage, 
but convulsions appear to be less common than in small-pox. With the 
progress of the fever, the catarrhal symptoms are apt to become more vio- 
lent, especially the bronchial. During this stage of the malady, the stomach 
is apt to become irritable, and vomiting is not unusual. 

On the third or fourth day, rarely as early as the second, or later than the 
fifth, the rash makes its appearance. The fever does not then abate as in 
small-pox, and may even become more violent till the sixth or seventh day, 
when, if no internal complication should keep it up, it goes off. The rash 
begins on the forehead, extends to the face, which sometimes swells as in 
small-pox, thence it extends to the neck, arms, and trunk, and finally reaches 
the legs and feet. It appears in dots of a dark red, which are aggregated 
into patches, some of which are rudely lunate. They are very slightly 
elevated above the surface of the surrounding skin ; and here and there 
present papulae, some of which become vesicular; but the fluid is removed 
by absorption, and scabbing does not occur. I have repeatedly seen cases 
which, on the first and second day of the efflorescence, could not be told 
from the eruption of varioloid, in the corresponding stage of that disease. 
The catarrhal symptoms will then aid us in the diagnosis, but all doubtful 
cases should be held subjudice, as to mistake the more, for the less dreaded 
disease, would bring odium on the physician. By the time the rash has 
established itself upon the feet, it will have faded on the face ; and by the 
eighth or ninth day will be gone from the whole body. As it declines, an 
exfoliation of the cuticle, in minute branny scales, takes place j in some 
cases so sparingly as not to be observed without close attention, in others 
abundantly ; and during this process there is generally an itching of the 
skin. It has been said that the rash, after declining, sometimes reappears 
with a renewal of the fever. As measles and scarlatina often prevail at the 
same time, it may be asked whether this second efflorescence was not the 
latter disease ? In the year 1820 or '21, I met with a well-marked case of 
that kind. The aspect and heat of the surface clearly marked it as scarla- 
tina. When the efflorescence is at its height, the mucous membrane of the 



INTERIOR VALLEY OF NORTH AMERICA. 5S9 

fauces exhibits spots of a darker red, but ulceration does not take place. 
During the rash, or on its decline, a diarrhoea very often sets in, and some- 
times continues as a troublesome symptom for several days. The eruptive 
fever and the cough should abate as the efflorescence begins to fade, if not 
before ; and when either of them, or especially when both survive that stage, 
it is an evidence of internal difficulties presently to be mentioned. 

When measles prevail during an epidemic typhous constitution, they as- 
sume a malignant character ; and from the darker color of the rash, and 
the dark or livid hue of the mucous membrane of the mouth and throat, 
with or without petechias, have received the name of black measles. The 
pulse in these cases is unsteady and compressible; the efflorescence, prema- 
ture or protracted in its outbreak, misplaced, partial, and prone to recede ; 
the heat of the skin is often defective, and the signs of visceral congestion, 
thoracic, abdominal, or cerebral, are urgent. 

Pathology and Pathological Anatomy. — We may presume that aeriform 
infection which produces measles, is inhaled in respiration; but is it ab- 
sorbed ? and does it act on the mucous membrane before its admission into 
the blood ? The early appearance of catarrhal symptoms would seem to 
suggest an affirmative answer to the latter of these questions, but as they 
are not present in " natural" small-pox, which may be supposed to be pro- 
duced in the same manner as measles, a sounder conclusion is perhaps that 
the infection is absorbed. In whatever mode or on whatever part its im- 
press is made, a certain time is necessary to the development of its sensible 
effects. Of the insensible changes in the innervation or the blood which 
it works out during that period we know nothing. They are the efficient 
causes of the fever and catarrh (which arise simultaneously), while the 
efflorescence seems to have for its antecedent the fever. In this, however, 
as in most other diseases, our rationale of the symptoms is little better than 
a statement of their relations in time to each other. The rubeolous poison 
is then an efficient noxious agent, which produces a series of morbid actions 
in certain organs and tissues. Some of these, as the congestion of the 
mucous membrane of the anterior part of the respiratory apparatus, the 
fever, and the cutaneous rash, are always present, and constitute the essen- 
tial elements of the disease. Others are accidental, and consist principally 
of congestions and inflammations of the lungs, the bowels, the brain, and 
the ears. In these organs we find the sequelae of the disease in protracted 
cases and the lesions of structure after death, whether it occurs early or 
late in the attack. When none of these accidents or extensions of the dis- 
ease beyond its necessary limits arise, the case, although the legitimate 
symptoms may be intense, seldom proves fatal, as having run their course 
they subside independently of the assistance of art. The prognosis of a 
case is bad then, in proportion not so much to the violence of the legitimate 
symptoms, as to the want of their regular development, or to their exten- 
sion beyond the proper limits. Thus a severe coryza, a hot fever, and a 



590 THE PRINCIPAL DISEASES OF THE 

copious rash, may be followed by early and complete recovery ; while each 
of these affections may in turn be nearly absent, and the case terminate 
fatally. Indeed, their very absence is the sign of malignity and danger. 
At all times the chief danger in measles arises from extensive pulmonary 
congestions embarrassing the functions of respiration and circulation, or 
from the development of pneumonia or pleurisy, which may be fatal in a 
short time ; or assuming a subacute form terminate in hepatization or em- 
pyema. I shall give the history of one or two such cases under the proper 
head. If the patient have a tubercular diathesis, phthisis, or external 
scrofula, cervical or ophthalmic, is liable to follow. In some cases a mucous 
enteritis destroys life at an early period; but oftener it assumes a chronic 
form, and presents after death hypersemias and ulcerations of the membrane 
with swelling of the mesenteric ganglia. The brain appears to suffer less 
than the organs just named, but the ears sometimes become involved, and 
violent pains are succeeded by suppuration in the external auditory pas- 
sages. The eyes also are liable to inflammation, especially in adults, which 
occasionally assumes a chronic form, and constitutes one of the troublesome 
sequelse of the disease. The pathological state of the system in the cases 
in which the rash does not appear or recedes deserves great attention. It 
presents two varieties. First. The inflammatory orgasm may be very great, 
and an internal inflammation, commonly in the lungs, may prevent the 
efflorescence. Second. It may be prevented, in whole or in part, or may 
fade away or assume a dark and livid character, from deficient constitutional 
excitement. These opposite conditions of course require opposite plans of 
treatment, though by the people and routine physicians they are commonly 
met by the same means. Measles and scarlatina sometimes prevail together, 
and appear reciprocally to modify each other ; but I shall reserve the history 
of this combination till we treat of the latter affection. 

Treatment. — In many epidemics, the duty of the physician is nearly 
limited to a daily inspection of the case. Abstinence, diluent drinks, fresh 
air, and sometimes a mild aperient, constitute the appropriate treatment. 
Beyond these mild measures, the interposition of art has for its object not 
the removal of the disease, but the preservation of the patient from the ac- 
cidents which have been enumerated. When the eruptive fever is intense, 
it may be moderated by a single venesection, and the free administration of 
nauseants, refrigerants, and cathartics, of which I believe the best to be the 
compound of tartar emetic, calomel, and nitrate of potash, formerly known 
as Rush v s powder. I have often seen full vomiting followed by very happy 
effects. The cases requiring this antiphlogistic treatment equally demand 
an unabated supply of fresh and cool air. In this highly inflammatory 
orgasm, accompanied as it generally is with positive internal inflammation, 
the appearance of the rash may be retarded, and if stimulating means for 
throwing it out should be resorted to, the patient will be lost. None of the 
antiphlogistic measures must, however, be carried very far, or they will in- 



INTERIOR VALLEY OF NORTH AMERICA. 591 

terfere with the development of the rash. TVe have already seen that with 
its appearance the fever does not cease, and that in some cases its intensity 
increases. At the same time visceral, especially pulmonary, inflammations 
are set up, or if previously existing become more intense. Venesection and 
other antiphlogistic measures are not, therefore, to be limited to the stage 
which precedes the appearance of the eruption, as in small-pox, but may be 
required at any subsequent period. In other cases the cutaneous excitement 
and that of the system at large are too low to favor the explosion on the 
skin. The blood accumulates within, and anxiety, oppression, and dyspnoea, 
with a feeble and rapid pulse, and a dark and cool state of the surface, are 
present. These are the cases which demand a stimulating treatment; and 
without it the patient may die. A warm stimulating bath and a mustard 
emetic are now of signal service; hot herb teas, of which in popular belief, 
saffron is the best, are also beneficial, especially if paregoric be added; wine 
whey and ammoniated alcohol, may likewise be employed if the powers of 
the system should flag to an alarming degree. The capillary circulation 
being re-established, and the rash appearing with the ordinary floridness, a 
further administration of stimulants will be unnecessary, and even injurious. 

When the gastric irritability is very great, an epigastric sinapism or 
blister is of signal benefit. The diarrhoea sometimes requires particular 
attention. An active cathartic of ten grains of calomel or blue mass, ten of 
rhubarb, and one of ipecac, may be followed by a tranquil state of the 
bowels ; but in many cases a pill of opium and ipecac, at bedtime, or the 
cretaceous mixture, with laudanum after each evacuation, will be necessary. 
As the diarrhoea, however, seems, in many cases, to preserve the lungs 
from inflammation, the physician should rather aim at restraining than too 
suddenly checking it. 

When cerebral congestions productive of coma occur, the lancet, or ade- 
quate leeching and free purging, are required. 

It is, however, to the lungs that the physician should direct the most 
vigilant attention. In every stage of the disease, passive or active hy- 
peremias are apt to supervene, and, if unsubdued, prove immediately fatal, 
or continuing, eventuate in mucous ulceration, parenchymatous induration, 
pleuritic adhesions, or abscesses. The existence of pulmonary engorgement, 
or actual inflammation in any of the tissues, must be ascertained by the 
modes of investigation to be pointed out under the appropriate heads. To 
relieve the former an emetic is of much power. It may be followed by dry 
cupping or blistering. Actual inflammation will require the lancet — when 
the blood will generally be found sizy — scarification with cups, and subse- 
quently blisters. Nauseating doses of tartar emetic, neutral salts, diluents 
and demulcents, with opiated sudorifics in the decline, will be proper. A 
violent inflammation of this kind may arrest the development of the rash, 
or cause its retrocession, when the stimulants usually administered by the 
people to promote or restore it, may prove to be the cause of death. 



592 THE PRINCIPAL DISEASES OF THE 

The confidence of the people in their treatment of this malady results 
from its self-limited character, and its general freedom from a mortal ten- 
dency. An intelligent lady once sent for me to visit her children, and 
wished me to tell her whether they had the measles, adding that she could not 
decide, hut knew how to cure them, and preferred to use her own remedies. 

I have not seen an epidemic of malignant measles, and am disposed to 
think it almost unknown in the Valley. As the visceral engorgement and 
reduction of the vital forces are great in this variety, depletion from the 
bloodvessels can only be employed at the beginning, and then to a limited 
extent. Blistering may do good, and a stimulating emetic is admissible. 
But much reliance should be placed on tonics and stimulants. An acidu- 
lated decoction of bark; opiates, wine-whey, wine, whiskey, or brandy; 
infusion of serpentaria, camphor, ammonia, nutritious diet, and stimulating 
baths to the skin, are the means most likely to carry the patient safely 
through. 

On the whole the period of greatest danger in measles is that of convales- 
cence. After the fever and rash have subsided, the circulation is peculiarly 
liable to lose its equilibrium under an exposure of the surface of the body to a 
cool and damp atmosphere. In common with other physicians, I have seen 
many sudden deaths from this cause. The blood is repelled from the surface, 
which suffers great reduction of temperature, and assumes a dark or livid 
hue. It simultaneously accumulates and stagnates in the vessels of the 
brain, the portal organs, or the lungs and heart, producing fatal oppression, 
accompanied by convulsions, or incessant vomiting, or distressing dyspnoea, 
according to the seat of the engorgement. At the same time the pulse is 
weak and fluttering ; and the signs of general debility extreme. The single 
indication of cure in this condition is derivation from the oppressed organ, 
and restoration of the peripheral circulation. In some cases a single bleed- 
ing, or scarification and cupping may be employed, and dry cupping may 
also do good. But our chief reliance should be on counter-irritation. A 
general and highly stimulating hot bath ; subsequent hot and irritating 
pediluvia; and the application of sinapisms or blisters to the parietes over 
the affected organs, are the measures upon which we should chiefly rely. 
When the local affection is beneath the diaphragm opium will be proper; 
and in all cases stimulating diaphoretics will co-operate beneficially with the 
external treatment. On the whole, however, the successful treatment of these 
cases is so difficult that we cannot too earnestly recommend to our patients an 
avoidance of the exposure which produces them. Exposure does not always 
produce the effects which have been described ; but occasionally awakens in 
some of the pulmonary tissues a subacute inflammation, which may go on 
to fatal organic lesions ; or a chronic diarrhoea eventuating in mucous ulcera- 
tion, or glandular congestions and abscesses in those who are prone to scro- 
fula. On the whole perhaps the management of a case of measles after the 
rash has faded, is as important as in any previous stage. 



INTERIOR VALLEY OF NORTH AMERICA. 593 



SUPPLEMENT. 

Epidemic of 1813. — As a supplement to this chapter, I propose to tran- 
scribe from my common-place book, a summary of the first severe morbillous 
epidemic which I ever witnessed in this place (Cincinnati). Ten or twelve 
years before, a similar one had occurred, but with less severity, than that 
of 1813. 

"The following were its general characteristics : — 

" 1. In the months of February and March, there occurred several severe 
and protracted cases of pulmonary inflammation ; and a number of deaths 
among those who labored under chronic diseases of the lungs. There were 
also many cases of sore throat (angina tonsillaris et pharyngeal, some of 
which were accompanied with fever, and some with slight ulceration of the 
mucous membrane. 

"2. The measles began to appear about the middle of March, and were 
at their height in May and June, after which they declined, but did not 
disappear till November. 

u 3. A great number of persons were attacked who had escaped repeated 
exposure to the infection before, and some are said to have had the disease 
a second time, which induced a number of persons to suppose the epidemic 
not to be measles. 

" 4. The fever attending it was as usual of an inflammatory kind. 

" 5. In a few cases the eruption appeared without any previous indispo- 
sition. 

" 6. In many cases, the rash terminated without any production of branny 
scales. 

" 7. Redness of the throat with small ulcers were common, and many 
had this affection who had already passed through the measles, and were 
not otherwise indisposed. 

u 8. In the months of March and April, a diarrhoea generally accompanied 
or followed the disease. In May, June, and July, the dysentery took its 
place, and sometimes proved fatal. 

"9. In several instances severe inflammation of the lungs occurred, and 
in one terminated in empyema. 

" 10. In a number of families, a part only of the members liable to the 
disease were seized with it." 

Severe Affection of the Brain in Measles. — Dr. Sprague,* of the State of 
Michigan, in 1844, saw an epidemic in which the signs of cerebral conges- 
tion and inflammation were greatly developed in almost every case. A 
majority of the patients died. 

* Western Lancet, vol. iv. p. 298. 
vol. ii. 38 



594 THE PRINCIPAL DISEASES OF THE 

CHAPTER VI. 

SCARLET FEVER— SCARLATINA. 



SECTION I. 

HISTORICAL NOTICES. 

A malignant form of scarlatina seems to have invaded the first settlers 
of Kentucky and Ohio, concerning which, however, but little is now known. 
Even the exact period cannot be stated, but it was between 1791 and 1793.* 
In Kentucky, where it was extremely fatal, it was universally called " putrid 
sore throat/' as it was probably unattended with much efflorescence. At 
Marietta and Bellpre, the oldest settlements of the State of Ohio, it was 
most dreadfully destructive among children and young persons, attacking 
and destroying nearly all the former. Five or six in some cases died out 
of a single family. In many instances parents lost all they had. It is 
worthy of remark that at the time of this epidemic, the country was an 
almost unbroken forest, the immigrants lived in open cabins, and subsisted 
on a simple diet, very often deficient in quantity. 

From the time of this epidemic till the year 1808, I do not know that 
any form of scarlatina appeared in the valley of the Ohio. In that year 
cases of the anginose variety began to show themselves in Cincinnati, and 
the disease prevailed more or less for two or three years. About the same 
date, Dr. Hildreth, who had immigrated to Marietta a few years before, 
observed the fevers to be of a " highly putrid" or malignant type; no actual 
scarlatina, however, occurred at Marietta till 1824, when it appeared in the 
anginose form. Three years before, 1821, it had broken out in Paris, 
Kentucky,"!* as a malignant sore throat, being unattended with a rash. Dr. 
Warfield regarded it as a new disease in that quarter. 

Since these dates, that is for the last twenty or twenty-five years, it may 
be regarded as one of our endemics, having, as I suppose, at no time been 
absent from the "Valley of the Mississippi and the Lakes ; though many 
localities may not have been visited, while others have experienced repeated 
invasions. To trace them out would be a hopeless task, as the histories of 
most of them have not been written. On the whole, they have been far 
more frequent and fatal in the middle and northern than the southern states. 
Dr. CallaghanJ has published an account of an exceedingly fatal invasion at 
Pittsburg, Pa., beginning in the month of May, 1830, and ending or abating 

* Drake's Notices Concerning Cincinnati, 1810. Hildreth, MS. Mem. Also, in West. Jour. Med. and 
Phys. Sci. vol . i. 
f Dr. Warfield in the West. Jour. vol. i. for 1827. i Amer. Jour., New Series, No. 15. 



INTERIOR VALLEY OF NORTH AMERICA. 595 

in the following January. Dr. Carroll* has described the disease in an 
epidemic form, complicated with erysipelas, at St. Clairsville, Ohio, in 1833. 
From 1828 up to that time, it had prevailed, he tells us, in various localities 
in the southeast part of Ohio, around St. Clairsville, and proved extremely 
mortal. Dr. Dawsonf has described it as occurring in Green County, Ohio, 
in 1838-39 and 40. No case, he remarks, had been observed in that quarter 
for six or eight years before. It took on the simple and anginose forms. 
Dr. LawrieJ has given an account of its prevalence in the latter variety in 
Calloway County, Kentucky, in 1838. Dr. Reyburn§ has reported many 
cases of an epidemic in St. Louis, in 1845. They were generally of the 
same type with the last. 

These published accounts, however, give but a faint idea of the extent to 
which scarlatina has prevailed among us for the last quarter of a century. 
In my personal intercourse with physicians, I scarcely conversed with one 
north of the 33d degree of latitude, who had not seen the disease epidemic 
once or several times, though many south of that parallel had never met 
with it. 

Origin and Spread. — The malignant scarlatina of 1791-3, can scarcely 
be regarded as an introduced disease, for the reason that it prevailed in new 
settlements detached from each other, and so distant from the Atlantic 
States, as that the migration to them was a labor of many weeks. I recol- 
lect, indeed, that the physicians and people of Washington, then a princi- 
pal town of Kentucky, regarded the epidemic as depending on the state of 
the atmosphere, which, it was said, was such as to cause a rapid putrefac- 
tion of fresh meat, when elevated and freely exposed to it. In this remi- 
niscence, there is of course no other value than that of showing that the 
disease was not considered as having been imported from abroad. Indeed 
of its introduction into most of the localities in which it has prevailed, we 
absolutely know nothing. I have never been able to trace up a single visi- 
tation at Cincinnati to importation, by patient or families; nor as far as I 
know, has a case of that kind been clearly made out. When the disease 
begins in a town or country neighborhood, it has, however, generally pre- 
vailed for a while in some other not very distant ; but of the connection 
between the two epidemics, in the relation of cause and effect, we have very 
little exact knowledge. If propagated from one to the other, the fact is 
generally enveloped in obscurity. Prevailing for several months or a year 
in one place, the people of surrounding places, although maintaining the 
usual intercourse with it, will remain exempt. At length, however, having 
exhausted its subjects, it appears in some neighboring village j exciting our 
wonder that an atmospheric contamination should not have occurred in both 
at the same time; or that if infectious, it should not have spread thither at 
an earlier period. When it appears in a family, it seldom attacks all the 

* West. Jour, of Med. and Surg. vol. vi. t Ibid. vol. v. 

+ Ibid. vol. ii. § St. Louis Med. and Surg. Jour, vol.iii. 



596 THE PRINCIPAL DISEASES OP THE 

liable at the same time, but more commonly does so progressively ; while 
one child, in each of a number of neighboring families, may be seized simul- 
taneously. Presenting such habitudes, we need not be surprised that our 
physicians, like those of other countries, differ in opinion as to the mode in 
which it propagates itself. A part believe it never infectious — another part 
regard it as appearing and spreading solely by infection — a third, and larger 
portion, consider it to originate de novo, but to be capable of propagating 
itself; and the truth probably lies with them. I do not know that the ex- 
periments by which, in Europe, the disease has been propagated by inocula- 
tion, have ever been repeated in the Valley. 

Seasons, Subjects, and Varieties. — Scarlatina is less limited to a particular 
portion of the year than measles, and seems not to prefer the first six 
months over any others. Indeed it generally prevails less in spring, than 
in summer, autumn, or winter, presenting in this respect, a kind of anta- 
gonism to measles, though the two have often prevailed at the same time. 

In this, as in other countries, its subjects are generally children below the 
age of puberty, especially under the tenth year. In early life, both sexes 
appear to be equally liable; but in middle life, women are more susceptible 
than men.* In old age, the liability to this disease appears to be less than 
to measles. As a general fact, it affects the individual but once ; to this, 
however, there are many exceptions. 

In common with all other epidemics, scarlatina presents varieties which 
are at the same time grades of intensity; but it goes beyond all others in 
its degrees of dauger. Simple scarlatina is almost unattended with any 
pharyngeal affection, and is equally free from danger. Anginose scarlatina 
involves both the skin and the mucous membrane of the throat, and is much 
more severe and mortal. Malignant scarlatina leaves the former almost un- 
affected, and concentrates its local manifestation on the latter. The first of 
these grades or varieties scarcely demands medical treatment — the last 
almost sets it at defiance. Of the causes or conditions which determine 
these remarkable diversities of phenomena and danger, we are entirely 
ignorant. They often occur simultaneously in neighboring localities. 

Symptoms.— The histories of this malady presented in European works, 
and in the writiDgs of our brethren of the old states, apply with but little 
modification to the disease as it prevails among us, both in the North and 
South. As we have just seen, these histories embrace three varieties, of 
which I shall proceed to give the characteristic symptoms. 

1. Scarlatina Simplex. — Many cases of this variety are so slight, that 
the patient continues on his feet throughout the attack ; but the more deci- 
ded cases are ushered in with a smart chill, succeeded by early reaction, a 
hot skin, considerable thirst, and a feeling of heat in the mouth and throat. 
Duriug the chill, nausea and vomiting sometimes occur, and in the reaction, 
delirium is not uncommon. The fever does not cease like an ephemera, 

* Library of Medicine, vol. i. 



INTERIOR VALLEY OF NORTH AMERICA. 597 

though it may display some remission, and then become still more intense 
on the second day. In many cases the rash now appears, and is rarely de- 
ferred beyond the third day, the fever, as in measles, continuing unabated. 
I have generally seen it visible on the upper part of the breast before any 
other part, whence it extends to the arms and face, and thence, within 
twenty-four or thirty-six hours after its first appearance, over the surface 
generally. The bright red dots rapidly multiply, and by an apparent 
coalescence, large patches of skin soon assume a uniform scarlet hue. To 
the eye, there is but little elevation of the parts which are thus overspread, 
but the hand will often detect a papular eruption, and minute vesicles are 
not uncommon. In this stage of the disease, the heat of the skin is of en 
considerably above that of ordinary fever; and the uncomfortable feelings 
of the mouth and throat are aggravated, the papillae of the tongue becoming 
prominent by sanguineous injection. On the fifth or sixth day the fever be- 
gins to abate, the efflorescence fades, and an extensive desquamation of 
the cuticle is followed by immediate convalescence ; in the progress, or 
after the apparent completion of which, however, anasarca more or less exten- 
sive, may supervene, and continuing for a short time, pass spontaneously 
away. 

2. Scarlatina Anginosa. — As measles are ushered in with a " cold in 
the head," so this variety of scarlatina is accompanied, sometimes indeed 
preceded, by a quinsy. A tendency to this is perceptible even in the 
mildest forms of simple scarlatina; its full development, as a specific inflam- 
matory congestion of the mucous membrane of the mouth and throat, often 
extending to the subjacent parts, constitutes the diagnostic distinctions of 
this form or grade of scarlatina as compared with the other. Of course 
cases constantly arise which may be regarded as violent grades of one or 
mild grades of the other ; and be referred to either head according to the 
arbitrary decision of the physician. In general, the fever is more intense, 
the efflorescence more universal, and the heat of the skin more elevated in 
this form than the other. In fact, we know of no other disease in which 
the temperature of the surface rises so high, many different observers having 
seen it at 108°, 110°, or even 112° of Fahrenheit. The rash, in this 
variety, is generally one or two days later in appearing than in the simple 
variety, is seldom so universal, and often partially recedes and reappears. 
The organic oppression, restlessness, delirium, and prostration, are in most 
cases very great. When inspected, the mouth, palate, tonsils, and pharynx, 
are found of a deep red, sometimes presenting spots of a purple hue, and 
others which appear like sloughs, but are removable, and held by the best 
pathologists to be composed of coagulable lymph, thrown out by the inten- 
sity of the inflammation. Ulceration is, in fact, not a common occurrence, 
nevertheless it sometimes occurs. Several years ago, I saw a case in which 
it attacked the base of the epiglottis, and during convalescence that organ, 
nearly detached, was drawn into or upon the rima of the glottis in such 



598 THE PRINCIPAL DISEASES OP THE 

manner as to produce suffocation and immediate death ; the cause of which 
was ascertained by post-mortem inspection. The tongue, in this condition, 
is sometimes swollen, its edges are red, and its papillae, in a state of tension, 
project through the white fur which covers its surface. The tonsils and 
uvula often swell so as to obstruct deglutition, and the former sometimes 
suppurate. The swelling and inflammation extend to the adjacent parts, 
involving the sublingual, submaxillary, and parotid glands, and sometimes 
the cervical ganglia; the muscles of mastication and swallowing participate 
in the inflammation, and those functions become impaired. A tenacious 
secretion covers the surface of the alimentary membrane, and subjects the 
patient to much inconvenience. But these lesions as seldom extend to the 
respiratory apparatus, as do those of measles to the digestive. Appearing 
before the efflorescence, these anginose affections generally survive it, though 
they begin to abate as it begins to fade. As long as they continue, some 
degree of fever generally lingers in the system. Now and then cellular or 
glandular suppurations about the neck, or in the auditory passages, prolong 
the sufferings or discomforts of the patient, and protract his convalescence. 
When leeches have been applied, the bites now and then ulcerate, and pro- 
duce troublesome sores. Among the permanent lesions of the throat, 
though of rare occurrence, is obliteration of the Eustachian tubes by adhesive 
inflammation. 

Thus far we have dealt with the necessary or essential symptoms of the 
disease; it remains to speak of its accidents and complications. These are 
found in all the great cavities, the organs of which may be either oppressed 
and irritated by extensive congestions, or experience actual inflammation, 
which, according to Dr. Tweedie,* is much oftener in their serous than in 
their mucous or cellular tissues. In this country the mode of fatal termi- 
nation presented by the disease, indicates it to be oftener from affection of 
the brain than any other organ. A large proportion of those who are lost 
die of convulsions in an early stage of the malady, or with manifest affec- 
tion of the brain at a later period. In an epidemic at Edinburgh, however, 
Dr. Hamilton*)* found that death was generally preceded by an extension of 
the disease to the larynx, trachea, and lungs. 

3. Scarlatina Maligna. — In this variety — the putrid, ulcerous, or gan- 
grenous sore throat of the older writers — the hot inflammatory fever, which 
has been described, is replaced by one of a low, adynamic, or typhous cha- 
racter, presenting the signs of debility and cerebral disturbance which 
characterize that form of fever. The efflorescence is sometimes entirely 
wanting. In the epidemic which Dr. Warfield has described at Paris, 
Kentucky,^ it did not appear in a single case. In none does it show itself 
as early as in the other varieties, and in all is partial, of a darker or paler 
red, and prone to recede. In some cases petechise appear; the high tem- 

* Cyclopasd. of Pract. Med. t Libr. of Prac. Med. vol. i. 

% West. Jour. Med. and Phys. Scien. vol. i. 



INTERIOR VALLEY OF NORTH AMERICA. 599 

perature of the skin is not developed, and the heat of the extremities is 
often below the proper standard. The throat affection is nearly always the 
first part of this disease, and in some epidemics has preceded every other 
symptom for several days. Instead of the florid redness of the mucous 
membrane, a dark or livid hue prevails. The tongue speedily becomes 
brown, smooth, and cracked. Aphthae occasionally appear in the mouth ; 
its secretions and those of the throat are offensive to the smell, and often 
acrid ; sordes adhere to the teeth • ash-colored spots appear on the curtains 
of the palate and the tonsils, which, in some cases, are adhesive mucus, in 
some exudations of lymph, but in others sloughs. Occasionally the parts 
assume a gangrenous tendency, and extensive sloughing throws off the dead 
portions, or the patient sinks under the mortification. At other times, 
hemorrhages from the mouth or nostrils occur, and occasionally regurgita- 
tions of food or drink through the latter, when the patient attempts to 
swallow. As in the preceding variety, swellings, and sometimes suppura- 
tions, of a most vitiated kind, occur in the glands or cellular tissue about 
the throat and ears. The periods at which death occurs in this variety are 
very different. It often happens as early as the second or third day, and 
may not occur for as many weeks, during which the utmost efforts of art to 
change the mode of morbid action and support the vital powers will produce 
little or no effect. 

Scarlatina Faucium. — It has been long known that persons who have 
had the small-pox are liable, while nursing variolous patients, to experience 
a few pustules without any constitutional disturbance. In like manner, 
when scarlatina is prevalent, many persons suffer a sore throat without 
fever or efflorescence. I have not seen the disease epidemic without meeting 
with cases of this kind. They constitute the scarlatina faucium of Euro- 
pean writers. In St. Louis, Dr. Reyburn saw many instances of this 
affection, "attended rather with nervous malaise, than with vascular dis- 
turbance/' 

Prognosis. — It is an admitted fact, that scarlatina, commencing in the 
simplest and mildest form, may, without any assignable cause, suddenly 
assume a fatal character ; and this may happen with individuals, while hun- 
dreds around them are passing safely through the disease. A general 
character of mildness cannot then be made the basis of a favorable prog- 
nosis. A prevailing floridness of the skin, with early and extensive rash, 
augurs favorably, while a dusky hue, petechise, or pallor, are ominous. A 
quiet state of the bowels is auspicious. Dr. Dawson (loco citato'), observed 
that cases in which diarrhoea occurred invariably proved fatal. Dr. Rey- 
burn remarks, that cases which, in the beginning, were attended with a 
full, round, active, and even strong pulse, did well, while those in which 
the pulse was contracted, small, and sharp, proved severe and dangerous. 
Dr. Warfield (loco citato), repeatedly witnessed that the preservation of the 
muscular strength is no guarantee of recovery. His patients sometimes 



600 THE PRINCIPAL DISEASES OF THE 

continued to walk about till within a few hours of death. Children are 
more likely to recover than adults, and men than women, especially those 
who are pregnant or in a puerperal state. 

Complications and Consequences. — In winter and early spring affections 
of the lungs and pleura are most apt to supervene on scarlatina ; in summer, 
the complications are oftener abdominal, — thus showing the influence of 
the seasons in modifying the character of disease which arises independently 
of them. "When measles prevail, the two exanthemata reciprocally modify 
each other, of which we shall see proofs hereafter. Epidemic erysipelas 
also unites itself with scarlatina, — a combination to be considered under 
another head. 

The consequences or sequelse of scarlatina may be inferred in part at 
least, from its symptoms as already detailed. They consist largely in chronic 
inflammations of the eyes, salivary glands, or lymphatic ganglise of the 
neck j in suppurations of the internal or external ear, the latter continuing 
in a state of ulceration ; in obliterations of the lumen of the Eustachian tube 
already mentioned, and sometimes in partial or total deafness. When the 
individual was predisposed to scrofula or phthisis, that disease may be 
quickened into action. In some cases abscesses of the joints are added to 
the catalogue of ills. An inflammation raised during the disease in any 
of the viscera may remain, and go on to disorganization of the tissue in 
which it is seated. As we have already seen it prefers the serous, but the 
mucous membranes do not escape, and a laryngeal or bronchial cough, as well 
as diarrhoea, are among the consequences we are enumerating. The most 
characteristic and formidable consequence of this eruptive fever, however, 
is dropsy; generally of the cellular, but sometimes of the serous kind. It 
appears to be limited to the more inflammatory varieties of the disease, and 
only appears in a small proportion of them. Although placed among the 
sequelae of the fever, it has occasionally occurred and proved fatal within 
the first few days; in general, however, it shows itself in twelve, fourteen, 
or more, after the commencement of the attack. I have never seen it but 
as a moderate and transient anasarca, commencing generally in the face ; 
but in Europe it has frequently occurred in the form of ascites, hydrothorax, 
and hydrocephalus, when it is apt to prove fatal. The urine in these dropsies 
abounds in albumen, being coagulated by heat and the mineral acids. 

Morbid Appearances. — When patients die in the first days of the fever, 
it generally happens that no lesions of structure are to be found. Time is 
necessary to their production. The vital powers are overwhelmed by the 
impress of the poison, or the functions of some great organ have been 
arrested by an accumulation of blood, which has receded while the patient 
was in articulo mortis or after death ; or, as Dr. Tweedie* conjectures, the 
virus may have wrought in the blood a change incompatible with the con- 
tinuance of life. In evidence of this he has observed that the skin iu these 

* Cyclop, of Prac. Med. vol. iii. 



INTERIOR VALLEY OF NORTH AMERICA. 601 

cases runs rapidly into putrefaction. Internal lesions of structure are not 
wanting, however, in cases which have continued a little longer ; and those 
in the form of hyperemias, and serous or sero-lymphatic effusions are 
often found in the brain. The throat presents congestions of its mucous 
membrane, with deposits of lymph, and the tonsils are swollen; in one 
epidemic, Dr. Hamilton, of Edinburgh, found a similar condition of the 
mucous membrane of the respiratory apparatus. Now and then the peri- 
toneum shows signs of inflammation, and occasionally the mucous membrane 
of the bowels. An involvement of the kidneys is only found in cases which 
continued beyond the usual period, and especially where death had been 
preceded by dropsy ; the aspect they then present is mottled and granular.* 

Prevention. — It may with truth be said, that scarlatina is either not in- 
fectious, or that its infection, although it may not be abundant and diffusive, 
is remarkably adherent to the fomites which imbibe it, for cases are re- 
ported which require us to adopt one or the other of these alternatives. 
Would we then prevent the spread of the disease ? We must bear in mind 
the great length of time which is required to detach the infection from houses, 
furniture, and clothing. This can only be done by free ventilation, and a 
liberal use of hot water, for we know of no chemical agent which can de- 
compose the poison. 

As a means of rendering the system insusceptible to the action of the 
virus, and thus preventing the disease, it was some time since proposed in 
Germany, to administer belladonna, continuing it for some time in minute 
doses. The sensible effects of this administration are said to be an efflores- 
cence or rash resembling that of scarlatina, with a slight affection of the 
pharynx, mouth, and salivary glands. These symptoms, however, are not 
constant, and it is said are not necessary to the preventive effect of the medi- 
cine. The German formula, is water, one ounce, extract of belladonna, three 
grains, mixed; of which solution three drops are to be given twice a day to 
a child under twelve years, and an additional drop for each year over that 
age. I must confess that I should have little faith in such doses, and know 
from experience that much larger ones, may be administered with safety. 
Dr. Burrows has given a sixth of a grain three times a day. As yet but 
few experiments on this prophylactic method have been made in the Valley 
of the Mississippi. In no case in which I have tried it has the imitative 
rash appeared, or the real disease ; but the number of cases has not been 
great enough to justify a conclusion. Dr. Logan, | now of New Orleans, 
gave a considerable trial to the prophylactic, while in Charleston, South 
Carolina. Five grains of the extract in an ounce of cinnamon water, was 
his formula, of which solution, five drops were given night and morning to 
a child, at or under three years of age, adding a drop for every year above 
that age. In a few of the patients it produced a slight redness of the 
fauces and lips, with a faint efflorescence about the throat and cheeks. 

* Library of Med. vol. i. f New Orleans Medical Journal, vol. i. p. 60. 



602 THE PRINCIPAL DISEASES OF THE 

About fifty of the orphans of the asylum to whom the medicine was admi- 
nistered escaped the disease. Only six or seven new cases occurred in the 
establishment, after the exhibition of the medicine was commenced; though 
more than fifty of the inmates had been previously attacked. Dr. Reyburn* 
of St. Louis, attended a charitable institution where there were more than 
sixty children, all presumed to be liable to the disease. The first case oc- 
curred in the last week of August. On the 3d of September, the exhibi- 
tion of the extract to all the inmates was commenced, and after the middle 
of that month the fever ceased to occur; previously to which, the attacks 
became milder and milder. In no instance were any sensible effects from 
the medicine observed. The dose of the medicine is not mentioned. 

Considering the continued prevalence and mortality of scarlatina in all 
parts of our Yalley, it is discreditable to us that we have not given the pro- 
posed prophylactic a fuller trial ; especially as it involves no risk or incon- 
venience, and would not be resisted by parents. 

It would be in vain to speculate on the modus operandi of the belladonna 
in preventing scarlatina. We can only state the fact, that if it prevent the 
fever, it is by destroying the susceptibility of the nervous system to the 
impress of the infection. 

Treatment. — Once developed in the system, scarlatina runs its course. 
The function of the physician is limited to the preservation of life, and the 
abatement of such local affections as would leave permanent infirmity. To 
what extent can even these benefits be conferred by art ? A satisfactory 
answer to this question cannot, perhaps, be given. Some physicians rely 
on bloodletting, others on emetics \ some on cathartics, others on ice or cold 
water; these on diffusible stimulants, those on the medicine expectante ; 
and each believes the plan he has adopted to be that which conducts the 
patient most safely through the disease, while in fact the diversity bears 
testimony against the pretensions of the whole, and justifies the question, 
whether the results would not have been the same, if nothing had been 
done ? whether those who have recovered, would not have done so if they 
had been left to nature ? and whether those who died under one method of 
treatment, would not have perished under any other ? In other words, are 
the modifications of action which our methods of treatment introduce, of a 
kind either to promote the chances of recovery, or to increase the danger of 
a fatal termination ? 

Mild and simple cases should beyond all doubt be left to nature, allowing 
the patient according to his instincts a bountiful supply of pure water and 
fresh air. 

The anginose cases in which the quinsy is decided, the fever burning, 
and the skin red and hot, present strong temptations to the interference of 
art. Even here, however, if there should not be signs of inflammation in 
any of the great organs, the antiphlogistic treatment may be limited to cool 

* St. Louis Med. and Surg. Jour. vol. iii. p. 346. 



INTERIOR VALLEY OF NORTH AMERICA. 603 

air, and cool water applied to the surface, with ice about the throat. 
The remarkable morbid activity of the calefacient function in such cases 
suggests these refrigerants, which can never do harm unless there should 
be an (undetected) inflammation of the lungs, while they certainly contri- 
bute much to the comfort, if not to the ultimate safety of the patient. In 
the management of these cases, however, we are apt to add to these simple 
antiphlogistics others of a more artificial character, which affect the consti- 
tution far more deeply. It is proper to consider them separately. 

1. Bloodletting. Although employed by many of our physicians, the 
experience of the majority tallies with my own, and goes to prove that vene- 
section is of uncertain benefit. I have bled little patients till they fainted 
(a practice that should not be imitated), and seen them die afterwards. In 
such cases, the vital forces are reduced, but the vital actions are not changed, 
and the systems of children are rendered irritable, thus increasing the danger 
of spasms, internal congestions, and revulsions from the surface. The older 
the patient, the less is the probability of these sinister effects from copious 
venesection, and the greater the probability of advantage. A second vene- 
section can hardly ever be required, and is seldom admissible, unless an 
acute internal inflammation has supervened in a vigorous constitution. Even 
then no experienced physician expects to find in venesection the resource 
which all experience shows it to be in the acute inflammations of the same 
parts from common causes. Nor is it equally valuable in every epidemic. 
Thus the first time that Dr. Ames saw it prevail at Montgomery, Alabama, 
bleeding was generally employed, and little else done, and every patient 
subjected to it recovering; but in a subsequent epidemic it failed. 

If local bleeding is of less efficacy than venesection, when the organism 
at large is to be influenced, it commends itself to us as a means of relieving 
topical affections, and may often be employed when general bleeding is in- 
admissible. If the brain should be specially affected, leeches may be applied 
to the temples and nucha: if the anginose symptoms be urgent, or otitis, 
ophthalmia, or parotitis, should supervene, leeching or cupping on the back 
of the neck should never be neglected ; although they do not always arrest the 
inflammation, and the wounds are sometimes followed by a vitiated ulceration 
extremely difficult to arrest. In the St. Louis epidemic, Dr. Reyburn found 
local bleeding decidedly and rapidly beneficial. In the St. Clair epidemic, 
Dr. Carroll found the same advantage in cupping, especially when the brain 
was deeply implicated. 

2. Emetics are in common use throughout the Valley; and the reports 
are generally in their favor. They may be administered when venesection 
is not admissible; but when the fulness and force of the pulse are great, 
the latter is a good preparative. The influence of vomiting on the circu- 
lation, which it reduces and equalizes, on the skin, the actions in which it 
tends to change, but especially on the throat, in arresting the inflammation, 
altering the secretions, and detaching adherent mucus and lymph, indicate 



604 THE PRINCIPAL DISEASES OP THE 

sufficiently the modes in which it may prove beneficial. If laryngitis or 
bronchitis should be present, vomiting may be still more demanded. It 
may be induced by a free and rapid administration of the medicine ; or pro- 
duced as an occasional or incidental effect, while the medicine is given in 
nauseating doses. The latter method is preferable in cases of a highly in- 
flammatory character : the former, when early exhaustion is anticipated. 
The emetics most in use are ipecacuanha and tartarized antimony. The 
first, at all times genial to the systems of children, is in most general use ; 
and will perhaps always maintain the relative rank it has long held. The 
second, more directly sedative, is well fitted to cases of high phlogistic action, 
in which it may be advantageously combined with nitrate of potash, and 
given in broken doses. After free vomiting, it is highly beneficial to ad- 
minister a dose of paregoric, laudanum, or the sulphate of morphia. 

3. Purging~is resorted to by most of our physicians, and as a means of 
reducing the morbid excitement of the surface, it deserves great confidence. 
The inevitable effect of purging is introversion of the currents of the circu- 
lation, and consequent abatement of the inflammatory congestion and inor- 
dinate heat of the skin ; effects obtainable by venesection at the expense of 
the fibrin of the blood, and at the risk of developing constitutional irritation, 
while by purging they are procured by natural revulsion. Again, when 
inflammation of the membranes of the brain has supervened, profuse purging 
may make powerful and salutary diversion from the head, affording a relief 
which no other therapeutic agency could impart. To continue purging after 
the heat and bright redness of the skin are reduced, is always injurious, 
for the morbid action set up in that tissue is a legitimate portion of the dis- 
ease, and should be allowed to run its course, If, when the skin has lost 
its inordinate heat and high color, there should be cerebral symptoms which 
call for revulsion, local bleeding and counter irritation should be substituted 
for further alvine evacuation. At night, after such evacuation, except when 
the brain is manifestly the seat of inflammatory hyperaemia, the administra- 
tion of a gentle opiate will be highly beneficial. Of cathartics, the best is 
calomel, which may be quickened in its action by minute doses of tartarized 
antimony, or by jalap, or an infusion of senna and manna, to which, in the 
case of children, it will always be judicious to add spigelia as a vermifuge. 

4. The superior efficacy of calomel must not be referred to its specific 
action on the biliary apparatus, seldom particularly involved in this fever, 
but to its power over serous inflammation, to which, in scarlatina, there is 
so great a tendency. Hence repeated doses of that medicine should not be 
regarded as altogether an empirical practice, although even a salivation 
cannot arrest the progress of the fever ; and in children it should never be 
so given as to run the risk of producing that sinister effect. 

5. I have already spoken of the value of water in simple scarlatina, where 
its limited application only is required. In the grade or variety of the 
disease now under consideration, it becomes a remedy of far greater impor- 



INTERIOR VALLEY OF NORTH AMERICA. 605 

tance. Indeed, of all the measures proposed in acute cases of scarlatina 
anginosa, it is, perhaps, the most valuable. Its use is general throughout 
our Valley, and the reports are nearly all in its favor. I have long been accus- 
tomed to prescribe it, and, on the whole, had much reason to be satisfied 
with its effects. When the heat of the skin is excessive, accompanied as it 
always is with great restlessness, extensive washing, or the actual affusion 
of buckets of water just from the fountain (and it should never be colder), 
diminishes the temperature, appeases the restlessness, reduces the inordinate 
frequency of the pulse, and for a time greatly improves the condition of the 
patient. When the cutaneous excitement revives, the affusions may be re- 
peated; but if the reaction should be slow, and a purple or livid hue should 
replace the scarlet tint existing when the application was made, it must not 
be repeated. Of its topical applications those to the throat and head are 
the chief. Pellets of ice may be held in the mouth, or slowly swallowed; 
and soft towels, dipped in ice-water, may be wrapped round the neck, or 
gently pressed against the throat, and continued after the time when it 
would be proper to employ general affusions. When delirium, or coma, or 
severe headache, indicates cerebral lesion, cold applications to the scalp will 
be among the most efficacious means of relief. To this end, no reliance is 
to be placed on a wet, folded rag, laid on the hair of the crown of the head 
(the people's favorite mode), but the entire scalp should be freely sponged 
every few minutes, and evaporation promoted by fanning or a current of 
external air. In the condition of the brain and its membranes demanding 
these applications, the feet are apt to be too cool, in which case, immersing 
them in hot water will harmonize with the refrigerating applications to the 
head. When ophthalmia supervenes, water is one of the best resources of 
the profession. It may be poured on the eyes, and injected within the lids, 
and will in general be found most acceptable to the patient, if it be not 
very cold. Its power over otitis is less, from the deep and insulated 
situation of the parts which are the seat of that affection. 

6. I cannot regard blisters as of great value in anginose scarlatina. If 
the rash should not appear at the proper time, and a stimulating application 
to the skin be demanded, they are inferior to sinapisms, which act more 
promptly, pungently, and transiently. As a means of moderating the fever, 
they are worse than useless. It is, in fact, for the relief of local affections 
only that they should be applied, and then topical bleeding, followed by 
cold applications, is to be preferred. When the affection of the brain is 
obstinate, and the power of bearing leeching or cupping seems to be ex- 
hausted, a blister to the nucha may do good; and applied to the same part, 
it may moderate the affection of the throat. 

7. Applications to the fauces are never neglected in this disease, but 
often made so inefficiently as not to extend below the uvula and front 
curtains of the palate, to which the back part of the tongue presses itself 
when we attempt to apply a wash. To reach the tonsils and pharynx, the 



606 THE PRINCIPAL DISEASES OP THE 

child's head must be firmly held by an assistant, and the tongue depressed 
with a finger, or a non-metallic spatula. To effect this, the pressure must 
be firmly sustained for many seconds, until the patient begins to gag, when 
the upper extremity of the pharynx and tonsils will be completely exposed, 
and a soft large mop, saturated with the gargle, may be boldly thrust 
against the back part of the pharyngeal walls, or the solution may be in- 
jected by a syringe, the stream being rapidly carried over every part. The 
coughing, hawking, or retching that succeeds detaches from the mucous 
membrane whatever deposits of mucus or lymph may be upon it, or sloughs 
which may have been previously loosened, while the impress of the gargle 
on the inflamed or ulcerated membrane or tonsils proves beneficial. Another, 
but inferior mode of obtaining the same result, is by forming the medicine 
into a linctus, or, combining it with white sugar, into a powder, to be laid on 
the tongue, and suffered, as it were, to glide or trickle into the fauces. In 
common cases of anginose scarlatina, attended with an inflammatory dia- 
thesis, the best gargles are the chlorides of soda or lime,* and the best 
powder is a compound of nitrate of potash or borax (biborate of soda), pow- 
dered gum Arabic, and refined sugar, intimately mixed by trituration. 

The malignant variety of scarlatina admits but few of the antiphlogistic 
measures which have been enumerated. Venesection and active purging 
are forbidden, and the general application of cold water is inadmissible. 
Emetics, however, are not to be rejected; but, on the contrary, are as valu- 
able in this variety as in the more inflammatory. But the adynamic state 
of the system requires that the most stimulating ones should be employed. 
Of the whole, mustard in warm water, the wine of ipecacuanha, an infusion 
of lobelia inflata, or an infusion of eupatorium perfoliatum with powdered 
ipecac, is the best. To promote gentle alvine evacuation, pills consisting 
of one part of capsicum, two of blue mass, and three of rhubarb, may be 
occasionally administered, or, in place of them, an infusion of senna, manna, 
and orange peel, or the tincture of rhubarb with gentian. A stimulant or 
tonic carried through the whole length of the intestinal canal, in connection 
with a laxative, will prevent the exhausting influence of the evacuation. 
Although venesection is inadmissible, leeching and cupping may be em- 
ployed, when the cerebral or anginose symptoms are urgent ; and while the 
general application of cold water is improper, it may be topically applied to 
the throat, cervical ganglia, and scalp, with advantage. Blisters must be 
used with caution from the prevailing tendency to gangrene. 

By common consent, the active and only efficient treatment in this form 
of scarlatina is the corroborant — constitutional and local. When the rash 
does not appear, and the skin is dark or livid, and below the proper tempe- 
rature, a stimulating bath with frictions may do great good; and if an 

* [Proper proportions are from J^j. to ^ij of Labarraque's solution to gj. of water, sweetened with 
honey.] 



INTERIOR VALLEY OF NORTH AMERICA. 607 

emetic should be so administered as to operate at the same time, so much 
the better. 

Of internal tonics, there can be no doubt that the bark is decidedly pre- 
ferable to any other; and its administration may be commenced soon after 
the patient has ceased to vomit. It may be given in drachm doses every 
two or three hours in wine ) or an ounce of the officinal decoction acidulated 
with elixir vitriol may be exhibited at the same periods j or an acidulous 
solution of quinine, containing one, two or four grains of the sulphate, may 
be substituted for both. As a powerful and permanent tonic, the bark is 
more to be relied upon, however, than the quinine. The doses proposed are 
for adults, and must of course be reduced for children. 

Bitter tonics and stimulants of other kinds have been proposed ; but why 
should we diversify our prescriptions, when we already have the best? If 
the powers of the system fail under the use of the cinchona, the case is hope- 
less. It is proper, however, to employ adjuvants, such as wine of a good 
quality, porter, old whiskey, or genuine French brandy, opium in quantities 
sufficient to produce and maintain a slight degree of narcotism, and car- 
bonate of ammonia dissolved in a sweetened infusion of capsicum. To these 
may be added broths, rich in gelatine, and rendered stimulating with salt 
and black pepper, or amylaceous jellies with wine, nutmeg, and other con- 
diments ) or strong coffee and boiled milk in equal proportions. The diffi- 
culty of deglutition is often so great as to make it proper to employ the most 
concentrated aliment. 

Applications to the throat appear to be of greater importance in malig- 
nant than anginose scarlatina ; and should always be of a more stimulating 
quality. I have used with advantage a formula which had been employed 
in the West Indies for more than half a century, and which Dr. Warfield 
in the Kentucky epidemic of 1827 found beneficial.* It consists of two 
tablespoonfuls of cayenne, and one of common salt, infused in half a pint 
of boiling water, and the same quantity of hot vinegar. After standing 
hot an hour to be strained. With this the throat may be mopped, or the 
medicine may be swallowed at short intervals in tea or tablespoonful doses, 
according to the age of the patient. In the latter mode of exhibition its 
effects are both local and constitutional. In the epidemic just mentioned 
Dr. Warfield also used a gargle of bark, borax, and tincture of myrrh in 
water with great advantage. The ingredients of this formula are in fact 
those which are in general use. The tincture of myrrh and honey in equal 
proportions applied with a mop are good. Water rendered sour with muri- 
atic or oxy-muriatic acid, and sweetened with honey is a valuable gargle. 
But no application to the throat is superior to a solution of chloride of lime 
or soda, made stronger than that directed in scarlatina anginosa. From 
analogy the tincture of iodine might be expected to do good. The nitrate 
of silver and sulphate of copper in solution are deserving of confidence ; 

* West. Med. and Phys. Jour. vol. i. 



608 THE PRINCIPAL DISEASES OF THE 

but the former from its ready decomposition, by the muriates of the mucus 
of the throat, should be made much stronger than we commonly employ it. 
When sloughing or gangrenous ulcers form, they should be touched with 
these escharotics in a solid form, or with a mop saturated with a caustic so- 
lution of subcarbonate of potash. 

Externally around the throat, Dr. Warfield applied an embrocation of 
proof spirit saturated with common salt. It produced redness, and in a day 
or two a pustular eruption, followed by the best effects. 

Of the anasarca consequent on scarlatina, but little has been said by the 
Western physicians who have written on the disease, or by any others with 
whom I have conversed, from which, in connection with my own experience, 
I infer that dropsy does not often follow on the scarlatina. I have seldom 
seen it in any other part of the body than the face ; and never knew it to 
be fatal. As a general fact the treatment of this affection should be that of 
inflammatory dropsy. The force of the circulation is too great, or the exha- 
lent function of the cellular or the serous membranes is over active from a 
condition of the capillary circulation not different from that of inflammation. 
It rarely happens, however, that venesection is required, and in general hy- 
dragogue purges and refrigerant diuretics will effect a speedy cure. Of the 
former, ten grains of calomel or blue mass, and the same quantity of squill, 
mixed and divided into four pills, one to be given every two or three hours, 
every other day ; or the sixth of a grain of elaterium, and ten grains of 
supertartrate 6f potash mixed, at similar periods, will prove equal to any 
other formula. Of the latter, a grain of squill and five of nitrate of potash 
in a powder, every two or three hours ; or an ounce of the infusion of digi- 
talis, with a drachm of spirit, nitr. dulc, three or four times a day; or a 
simple solution of crem. tart., to which if the patient be debilitated, gin 
and sugar may be added, will be sufficient ; but in most cases, the dropsy 
will yield to time, flannel, and frictions, to restore the functions of the skin, 
fresh air and gentle exercise, without a resort to any kind of active treat- 
ment. 



SECTION II. 

SCARLATINA AND MEASLES, COMBINED. 

It should not astonish us, that for a long time measles and scarlatina were 
confounded, under the former appellation ; for in addition to the resem- 
blance in their symptoms, they are occasionally epidemic at the same time 
and place. As far back as the years 1811, '12, and '13, I saw many evi- 
dences of this combination in Cincinnati. In the first of these years the 
scarlatinous influence predominated, in the last the morbillous. Thus we 
had scarlatinas which were accompanied with catarrhal symptoms super- 
added, and in some cases almost superseding the anginose symptoms, the 



INTERIOR VALLEY OF NORTH AMERICA. 609 

rash not displaying exactly the characteristics of either disease, while the 
majority of cases were well marked as scarlatina, and genuine measles did 
not appear. Gradually the latter epidemic gained the ascendency, and I find 
in my notes for the year 1813 memoranda of measles, in which the an- 
ginose symptoms indicated the presence of the scarlatinous poison in a re- 
duced degree. I have elsewhere mentioned a case, in a subsequent year, 
which presented scarlatina, in the convalescence from measles, indicating 
the presence in the system of both infections at the same time, but produc- 
ing their specific effects in succession and not in combination. 

Dr. Long, and Dr. Shirley, of Jacksonville, Illinois, have seen the two 
diseases prevalent at the same time at that place, when cases occurred in 
which the symptoms were blended. Angina supervened on catarrh, and 
the crescent-shaped spots of rash assumed a scarlet hue, with less elevation 
than is common in measles. Many persons who had previously experienced 
measles, went through attacks of this kind. 

At Canton, Ohio, Dr. Estep has seen the two fevers blended in a number 
of cases. The efflorescence was decidedly morbillous, but a sore throat re- 
placed the coryza, and was followed by suppuration of the cervical ganglia, 
pains in the limbs, and anasarcous infiltrations. In the same family, at the 
same time, he saw one patient with well-characterized measles, another with 
scarlatina equally distinct, and another with the compound affection. He 
has also seen one disease finish its course, and the other set in immediately 
afterwards, before there had been time either to receive infection, or for the 
period of incubation. 

In 1844, while travelling in Louisiana, I saw well-defined cases of scarla- 
tina, when the prevailing disease was measles. In the same year, Dr. 
McKelvey, of St. Francisville, in that state, when both diseases were epi- 
demic, saw a case in which the rash, for two days, was that of scarlatina; it 
disappeared and was immediately succeeded by that of measles, the eruptive 
fever seeming to have been common to the two maladies. In the same 
year, Dr. Fearn and Dr. Levert, of Mobile, saw measles and scarlatina so 
mixed up, that many cases could not be referred to either head; while 
distinct cases of both were occurring. In one instance, Dr. Fearn saw a 
well-marked scarlatinous efflorescence, in three days after the morbillous 
had disappeared ; I did not record whether it was preceded by an eruptive 
fever; but the infection which produced it had manifestly been received into 
the system while that of the measles was still in action, or before its effects 
were developed. Finally, Dr. Ames, of Montgomery, Alabama, has given 
me an account, which I published in the Western Journal,* of the com- 
mingling of these fevers in the spring of 1844. The scarlatina preceded 
the measles. The first case in his practice, occurred in the last week of 
January, and was attended with severe bronchial symptoms. The fever 
spread slowly till the end of April, when it suddenly ceased. The measles 

* Louisville, January, 184T. 

vol. ii. 39 



610 THE PRINCIPAL DISEASES OF THE 

began in the latter part of March, was most prevalent in April, and declined 
towards the end of May. Before and after the morbillous efflorescence began to 
show itself, the scarlatinous eruption was often accompanied with catarrhal 
symptoms; and on the other hand, the anginose affection of scarlatina was 
quite as often associated with a morbillous exanthem, after that form of efflore- 
scence became predominant. It was, indeed, difficult to decide by the symp- 
toms which preceded the eruption, to which head a case should be referred, 
and Dr. Ames had occasion, more than once, to change the name which he 
had entered on his note book. The following cases will afford an authentic 
illustration of this combination. 

Case. — H. W., five years old, was attacked, on the 13th of April, with 
the usual symptoms of scarlet fever, and cough. On the third day, the 
eruption was very distinct, and had the characteristics of this disease. On 
the fourth day, in the morning, these characteristics had disappeared, and 
those of measles had taken their place ; at the same time his face had be- 
come tumid, and his eyes red, suffused, and painful in the usual light. The 
eruption had now the distinctive signs of measles — in its appearance on the 
fourth day — in being accompanied by catarrhal symptoms — in occurring in 
small patches, circular or crescent-shaped, elevated and dark, with inter- 
vening portions of skin not affected. On the fifth day, the symptoms of mea- 
sles were mitigated or absent ; the rash, though faded, had resumed the ap- 
pearances of scarlet fever, except on a small part of the arms, near the 
wrists, and on the knees, where it had a vivid color, and retained the ap- 
pearance of measles. On the sixth day, no trace of measles could be 
discerned, except the cough, which was greatly aggravated. The ulcers on 
the tonsils had become deeper, dark, and offensive ; diarrhoea had super- 
vened; the abdomen had become tumid and tender, and the tongue dry and 
fissured. He died on the seventh day, apparently from enteritis. 

Case. — L. W., sister of H. W., aged ten years, was attacked on the 23d 
of April. The symptoms were those common to scarlatina, except an al- 
most continued sweating, which, at that time, was a common symptom of 
measles, and that the fever was a quotidian intermittent, distinct and regu- 
lar, and accompanied by a slight cough. The eruption came out on the 
third day, and occupied more surface than was common. On the fifth day, 
a catarrh, as decided as in any case in measles, appeared, with an increase 
of cough. At the same time, there was such a marked change in the ap- 
pearance of the eruption, as to be noticed with great alarm by her mother, 
who asked me, as soon as I entered the room, if the disease was changing 
to measles. Her attention was confined to the eruption, but on examining 
it carefully, I could see no change, except in its color ; it was darker, and 
had more of the raspberry tint of measles. On the seventh day, the ca- 
tarrh continuing, the eruption had disappeared entirely from the face and 
neck, and was faded everywhere else. On the eighth day of the disease, 
and fourth of the catarrh, the eruption of measles showed itself very plainly 



INTERIOR VALLEY OF NORTH AMERICA. 611 

on the face, neck, shoulders, and upper part of the chest. On the ninth 
day it was fully developed, without being extended beyond the parts which 
it occupied the day before. I did not observe any change in the scarlet 
rash j it did not recede, but remained in the same state as on the seventh 
day, until the rash of measles began to fade, and then followed the course 
of the latter, so that desquamation did not begin before the thirteenth day. 
After the measly rash came out, the fever became continued, without any 
abatement of the perspiration. The whole course of the complaint was 
mild, and convalescence went on favorably. 

Dr. Ames saw pertussis at the same time with the other epidemics, and 
several patients were attacked with one of those exanthems while affected 
with the hooping-cough : other physicians have witnessed the same combi- 
nation. He also observed, that the eruptive fever of measles and scarlatina 
in nearly all his patients, was remittent or intermittent, but became more 
continued when the inflammation of the mucous membranes was severe. 
This modification can be understood, by referring to the fact, that Mont- 
gomery and its neighborhood are infected with autumnal fever,* and that 
the eruptive epidemics occurred at the season when virulent intermittents 
prevail. Here there was the concurrence of the specific causes of three 
forms of fever — the periodical, morbillous, and scarlatinal; an alliance which 
instructs us that pathology, diagnosis, and therapeutics should be studied 
in connection with etiology. 

Let us for a moment generalize these facts. 

1. As they run through a period of thirty years, and a space of more 
than ten degrees of latitude, they teach us, that the combination of measles 
and scarlatina is far from being an uncommon event in our Valley. 

2. It appears, that the two diseases are often epidemic at the same time 
and place, each preserving, in the majority of cases, its distinctive cha- 
racteristics. 

3. Sometimes one influence is much weaker than the other, and is only 
able to render itself perceptible, which it may do in a number of cases. 

4. Now and then cases occur, in which the strength of the respective 
remote causes is so nearly equal, that the diagnostic symptoms of the two 
maladies are present in nearly the same proportions. 

5. Occasionally one efflorescence immediately succeeds that of the other, 
showing the incubation of the second to have been going on during the 
more advanced stages of the first. 

6. It often happens, that while but one is epidemic, well-marked sporadic 
cases of the other will occur. I have myself witnessed this both in Ohio 
and Louisiana, and others have testified to the same thing. 

7. Two etiological views may be taken of this union of measles and 
scarlet fever ; first, that those diseases are mere varieties of one species, and 
therefore disposed to unite in the formation of a new variety; second, that 

* See vol. i. p. 1ST. 



612 THE PRINCIPAL DISEASES OF THE 

they are distinct but closely allied species, members of the same genus, and, 
therefore, fitted to concur in the production of a mongrel, which, like other 
specimens of hybridity, is incapable of perpetuating its kind. This is doubt- 
less the correct view; and hence we have no morbillo-scarlatinal contagion. 
But in this coalition, does either disease preserve its power of propagation, 
or do both, or the one only which predominates in the morbid compounds ? 
These are questions which I am not able to answer. Nor can I say whether 
the individual in whose system the two poisons have been active at the 
same time, is afterwards in a state of immunity from both or either. 



CHAPTER VII. 

ROSE-RASH— ROSEOLA : ALSO LICHEN AND STROPHULUS. 

Every physician is aware of the diagnostic difficulties presented by the 
.eruptive diseases, which in the books of dermoid nosology, are referred to 
the heads of Roseola, Lichen, and Strophulus, under which they are divided 
into many species or varieties ; by Dr. Willan into no less than eighteen. 
As they are all more or less papulous, as in their acute forms the efflorescence 
is preceded by feverishness, and tends in most of them to produce a branny 
desquamation, it is easy to perceive that the labor of studying their diag- 
nostic relations is not small. Moreover, most of them occur but seldom ; 
very few of them require medical aid, and all or nearly the whole are free 
from danger. Opportunities and motives then for studying them do not in 
fact exist, and the most diligent inquiry among our physicians could not 
bring out much that would be worthy of publication. 

1. I have seen a few cases which answered to Dr. Willan's Roseola eestiva. 
They might have passed for mild cases of scarlatina. Indeed, it cannot be 
doubted that these affections have been often confounded, for in Roseola 
there is often a slight affection of the throat, quite as much as attends on 
some cases of real strophulus simplex. The scarlet hue of one, and the 
roseate tint of the other will aid us in a discriminating diagnosis ; but the 
conclusive point of distinction is the recurring tendency of Roseola. 

2. Lichen tropicus or prickly-heat, occurs every where throughout our 
Valley ; but here I might remark that the latter designation, like hives, is 
applied by the people, and most of our physicians, who follow them, to 
almost every kind of papulous eruption occurring in hot weather. But a 
few days since, the weather being hot, I saw a little girl, not three* years 
old, with a papulous eruption on one side of her neck, which, without any 
previous indisposition, had begun the night before, and was rapidly spread- 
ing. The next day it had descended upon her chest, and presented an aspect 
which excited anxiety in her parents. On the second day after it began, 



INTERIOR VALLEY OF NORTH AMERICA. 613 

her brother, about two years older than herself, experienced an attack of 
the same kind. In both cases there was no previous fever, and at the end 
of three or four days, the efflorescence disappeared with a furfuraceous des- 
quamation. This was called prickly-heat by the mother, and was one of 
the great variety of eruptions which have received that name. A nosologist 
would, I presume, refer it to Dr. TVillan's genus lichen, though it might puzzle 
him to bring it under any one of the Doctor's specific descriptions. The 
same remark would be applicable to many other cases to which the attention 
of the physician is casually directed, one of which I may give as an illustra- 
tion of the whole. 

A maiden lady, thirty years of age, who suffered more or less from dys- 
pepsia, with occasional protracted fits of hypochondriasis, but at the time in 
her best gastric health, with unusual buoyancy of spirits, on the 18th of 
May, 1841, began to feel a slight itching and burning on the left side of 
her neck, just above the clavicle, with redness of the part. On the next 
day, the spot had extended down upon the chest, and the sense of heat and 
smarting had greatly increased, but still she had no fever. Cloths dipped 
in tepid water were applied to the part, and on the night of the 19 th she 
took ten grains of calomel. On the 20th it was still spreading, and although 
papulae were discoverable, bore much of the aspect of erysipelas, and was 
accompanied with a feeling of intense heat, not at all mitigated by the 
operation of the calomel, — still she had no fever. Dusting it with starch 
afforded no relief. A solution of two and a half grains of corrosive subli- 
mate, in an ounce of distilled water, was applied, the effect of which, to use 
her own expression, was as if scalding water had been poured upon the part, 
though it was kept on but a few minutes. Cream was then applied, but 
afforded no relief; and a slippery-elm poultice was compared in its effects to 
the sublimate. Under these disappointments, she took an ounce of pare- 
goric. On the following night, 21st, she took a second dose of calomel 
combined with Dover's powder, and the next day, magnesia and lemonade, 
as a cathartic. To the inflamed parts mild mercurial ointment was applied, 
and afforded a partial relief. On the night of the 22d she took a syrup of 
sulph. of morphine, with wine of ipecac. On the 23d the ointment was 
continued, and at night she repeated the calomel and Dover's powder. On 
the afternoon of the 24th the itching revived, and became quite intolerable, 
when she laid aside the ointment and resumed the tepid water; at the same 
time the sense of burning occurred in spots on various parts of her body, 
which were seen to present a papulous appearance. The itching was urgent, 
and rubbing or scratching increased it, and extended the redness, at the 
same time she experienced a number of slight chills. As she had been 
copiously purged, she was now ordered to take the sulphate of quinine and 
Dover's powder, and a solution of acetate of lead was. applied to the skin, 
but neither afforded any relief. Her sufferings were now very great, and 
her morbid irritability extreme. On the morning of the 26th, she took an 



614 THE PRINCIPAL DISEASES OF THE 

active emetic. No bile was thrown up, but she was manifestly better, and 
from that time mended so rapidly, that on the 29th she was able to go out. 
On the decline of the inflammation the skin was rough. Throughout the 
whole of this tedious attack there was scarcely an hour in which fever could 
be detected. In every stage of it, the evidences of constitutional irritation 
were decided. It is probable that if she had taken an emetic on the first 
day of the attack it would have been at once arrested. 

3. Of strophulus, I may say that the variety denominated intertinctus, or 
red gum, is common among our infants, and as benign, or at least as free 
from danger as it is known to be elsewhere. 



CHAPTER VIII. 

NETTLE-RASH— URTICARIA. 

Prevalence. — Among the minor exanthems of our midland Valley, urti- 
caria is certainly the chief, and in the natural order I have adopted, ranges 
alongside of erysipelas, with which its etiological and diagnostic relations 
are, perhaps, greater than with any other. I have never seen a fatal case of 
this malady; but its distressing character, and its obstinate recurrence, in 
certain constitutions, render it an object of interest both to the profession 
and the people. It never appears as an epidemic ; but is by no means the 
rarest of our sporadic diseases, and is met with in every part of the Valley. 
Occurring in most cases as an acute disease, it now and then assumes a 
chronic form, not, it is true, existing all the time, but recurring under the 
influence of the slightest exciting cause. 

Diagnosis. — Urticaria, as far as the skin is concerned, presents an out- 
break of wheals, weals, whales, or whelks, that is, of spots resembling those 
produced by the sharp stroke of a whip or switch. These words, the last 
of which is preferred in this country, are supposed by Webster to be derived 
from a Welsh root, signifying a twig or small limb of a tree. As all per- 
sons have seen elevations produced by such an instrument, a reference to 
them is more instructive than a page of descriptive diagnosis. The names, 
both Latin and English, by which this assemblage of whelks is known, are 
equally instructive, as they refer to the spots produced by the sting of 
nettles. 

The people have for this affection still another name — hives; but as they 
apply it without discrimination to a variety of eruptions, it cannot be 
received as designating especially that now under consideration. 

When the whelks in urticaria are about to rise in any part, a slight and 
warm itching is felt, which leads the individual to rub or scratch it, when 
they instantly appear, not at all, however, to his relief; for the heat; 



INTERIOR VALLEY OF NORTH AMERICA. 615 

tingling, and formication, are increased, and the desire to scratch becomes 
urgent. Its indulgence, so far from affording relief, augments both the 
sensations and the number and dimensions of the whelks, which, at length, 
become confluent, and give to the part a tumefaction and redness, which a 
superficial observer might mistake for erysipelas, especially if seated on the 
face. Unlike erysipelas, however, urticaria appears on various parts of the 
body at the same time, and oftener in circular, oval, or oblong isolated spots 
than confluent patches. The height to which they rise is such as to suggest 
a great influx of blood, for nothing else could suddenly so distend a portion 
of the skin. Their summits, or central parts, are often white, while their 
declivities and margins are of a rose, or deep red color. Although they 
appear independently of friction, it is remarkable that during the continu- 
ance of an acute urticarious diathesis, scratching any part of the skin will 
bring them out. In duration they are essentially evanescent, occasionally 
disappearing in a single hour or less, then reappearing in some other part, 
and continuing the attack for a day or two. In nearly all the cases of 
acute urticaria which I have met with, the efflorescence was preceded by 
some degree of constitutional disorder. Sometimes a mild and short 
paroxysm of fever, but more commonly nausea, vomiting, and diarrhoea. 
On the sudden retrocession of the whelks, a feeling of general weakness, 
epigastric sinking, nausea, with apparent tendency to fainting, is experienced 
for a short time, when it passes away with or without a recurrence of the 
rash. Although an attack may be concluded in a few hours, it may be 
prolonged through several days or a fortnight, during which, however, the 
chief suffering of the patient will be the pruritus or itching, which is some- 
times annoying in parts where no whelks appear even under severe scratch- 
ing. I have never seen papulas, vesicles, pustules, or desquamation in this 
eruption. Authors speak of women and children as peculiarly liable to 
urticaria ; but it has happened to me to see it chiefly in men in the earlier 
years of middle life. As to seasons, I have met with it oftener in summer 
than any other. 

Remote and Pathological Causes. — Most acute and transient attacks of 
urticaria may be traced up to some internal irritation, generally in the di- 
gestive organs, sometimes in the uterine, never as far I have seen in the 
lungs or brain. In many cases the internal or radical affection is an irrita- 
tion of the gastro-intestinal mucous membrane, produced by some article of 
diet or drink, which from its indigestible character, or the bad health or 
idiosyncrasy of the patient, proves an irritant. On the shores of the Gulf 
of Mexico, or in other maritime districts, crabs, lobsters, and other shell-fish 
occasionally produce it. In the interior, indigestible articles taken to excess, 
especially in hot weather, occasion it. One of the most sudden and violent 
cases which I have ever seen, occurred in a man, who after a long ride, in a 
hot day, ate a hearty supper of cold " pot-pie," a well-known boiled compound 
of recently killed chicken, unleavened dough, butter, and black pepper. I 



616 THE PRINCIPAL DISEASES OF THE 

have seen many cases, however, which could not he traced up to any irregu- 
larity of diet, though generally occurring in dyspeptics, or those who drank 
to excess ; indeed a dehauch, in the earlier stages of a life of intemperance, 
is often followed by urticaria. Now and then it occurs as a contingent or 
anomalous symptom in our autumnal fevers. At Fort Gratiot, Dr. Pitcher, 
when in the army, saw many fatal cases in which urticaria appeared on skins 
which had assumed a golden yellow color. In the year 1809, 1 saw it occur with 
violence in a patient laboring under jaundice. A copious bleeding removed 
it, the jaundice still continuing. These etiological specimens will be suffi- 
cient to suggest both the 

Prophylaxis and Treatment. — Those who through idiosyncrasy expe- 
rience the disease from any particular article of diet or drink, will of course 
avoid such. Dyspeptics must eschew heavy meals of indigestible food, and 
employ the means proper for the removal of their habitual disease. Such 
as labor under chronic affections of the liver or uterine system must do the 
same. Excessive clothing in summer, and deficient in winter must be avoided ) 
and alcoholic drinks must be superseded by simple water. 

When the attack occurs, the first question should be as to the ingestion 
of any unusual or excessive quantity of food or drink, or the use of any 
article of medicine, which might have excited it, of which the stomach 
should at once be freed by an emetico-cathartic. If fever be present, a 
copious bleeding should precede the vomit; or if the disease should not 
cease on the evacuation of the stomach and bowels, the lancet then, if 
not before, is called for. After these evacuations, opium with or without 
a diffusible antispasmodic, such as ammonia or ether, should be adminis- 
tered to allay the nervous irritation, and prevent the patient from rubbing 
or scratching his skin. If the patient be habitually dyspeptic an antacid 
should be administered — if a child in the period of dentition, the gums 
should be cut — if after that time, a vermifuge ought to be administered. A 
tepid shower-bath or affusion will do good, and its effects be augmented by 
dusting the surface of the body with starch as soon as it is wiped dry. From 
the beginning, a copious use of diluents, with a little nitrate or bicarbonate 
of potash, will be proper. When upon a sudden recession of the wheals, 
the sense of epigastric sinking is great, a sinapism should be applied over 
the part. 

The following cases will serve to illustrate both the symptoms and treat- 
ment of this disease. 

Case requiring Venesection. — In the month of August, 1813, a robust 
gentleman, about 32 years of age, not very regular in his habits, arrived in 
Cincinnati from the western part of Illinois. Although able to travel on 
horseback, he consulted me for some fastidiousness of appetite, a slight pain 
in the region of the liver, and occasional flushes of fever. He took an 
emetic and two cathartics, discharged considerable bile, was relieved of the 
hypochondriac pain and felt better. Coming from a malarious region, I now 



INTERIOR VALLEY OF NORTH AMERICA. 617 

directed tincture of cinchona, of which he had only taken a single dose, 
when an eruption of large whelks occurred over most of his body. They 
presented a variety of forms, but were chiefly oblong or oval, whitish in the 
centre, and red in the border. The itching in them was intolerable, and 
extended, also, over the intervening skin, which on being scratched was im- 
mediately covered with the eruption. The face suffered most, exhibiting a 
tumefaction and redness quite erysipelatous. Even the palms of the hands, 
and the soles of the feet, quite back to the heels, did not escape. Conside- 
rable fever, accompanied with a white tongue, and a pain behind the ensi- 
form cartilage speedily supervened. Saline cathartics followed by small 
doses of Dover's powder, for twenty-four hours, procured but little relief. 
I then bled him twice in one day, to the quantity, in the whole, of twenty 
ounces, and dusted his face with starch, when he immediately recovered. 
The blood was not sizy. He had suffered attacks of the same disease before, 
but they were less violent. 

Case not requiring Venesection. — A young woman of sanguine tempera- 
ment and uncommonly sound constitution, without any known cause, felt 
slightly and undefinably indisposed in the forenoon, during which she de- 
scended into a cellar, when a slight chill came on. In a few minutes she 
felt an itching sensation behind her ears, and along the lower margin of the 
scalp between them. On scratching the parts wheals instantly appeared, and 
in a brief period covered her body, being most confluent on the face. She 
experienced at the same time a sense of suffocation, as though there was ob- 
struction in the larynx. Very soon she passed into a state of insensibility 
to surrounding objects, with a loss of consciousness, which continued for 
several hours, and was so perfect that she was afterwards unable to recollect 
anything which passed during that period. I did not attend her, but sup- 
pose from the account given me, that it was a kind of hysterical reverie. 
She was at length relieved by an emetic. 

Within a few years afterwards, when a married woman, she experienced 
two other attacks. 

In the month of June, 1841, ten or twelve years after the first attack, 
being at the time a widow and enjoying perfect health, she experienced a 
fourth. On the day of its occurrence, she breakfasted and dined on her usual 
diet. In the course of the forenoon she had two alvine evacuations, and in 
the afternoon felt a gloom for which she could assign no cause, either physi- 
cal or moral. In the evening she began to experience a burning and prick- 
ling sensation in the skin of her neck, spreading rapidly over her whole 
body, which was immediately covered with wheals. When I reached the 
house at eight o'clock, she had vomited a little, her face was red, her pulse 
one hundred and sixteen in a minute, her tongue pale but not furred, her 
mind agitated ; she thought herself in great danger, shed tears, and'complained 
of choking — in short had a fit of hysteria in connection with an outbreak of 
urticaria. I immediately administered 3iv of antimonial wine with Jj of lau- 



618 THE PRINCIPAL DISEASES OF THE 

danum, and soon afterwards another but smaller dose of the latter. She 
vomited a number of times, throwing up but little however; a part of the 
vomited matter tasted sour, which led me to administer a solution of car- 
bonate of potash. At ten o'clock she was much better. Her pulse had 
fallen twenty-four beats in a minute, that is to ninety-two; the rash had re- 
ceded, and the agitation of her nervous system had nearly ceased. She 
then took a dose of calomel, and I left her. The next morning I found that 
she had not rested well, but the wheals were gone. A dose of magnesia 
with lemonade was now ordered, and she was soon quite well. 

This case, both in its phenomena and treatment, show that while many 
cases of urticaria demand the lancet, there are others which are attended 
with constitutional irritation. 

Chronic Cases. — 1. A gentleman who had from early manhood labored 
under dyspepsia, unaccompanied with gastritis, when about thirty-two years 
of age was very much relieved by a liberal diet and the daily use at din- 
ner of whiskey and water. Some time after this salutary change, he had 
an attack of acute urticaria, which began with itching and an outbreak of 
wheals on the back of the neck and behind the ears. For some time after- 
wards he had an occasional return of the same kind. When in his fortieth 
year he suffered an alarming attack of cerebral congestion, for which he lost 
nearly one hundred ounces of blood, none of which gave signs of inflamma- 
tion. This was in the summer. As the cool weafher of the ensuing au- 
tumn came on, his extremities began to be affected with urticaria, which 
became habitual until the warm weather of the following year. He was at 
no time entirely free from it, but cold was the great exciting cause. When 
exposed during the winter, the itching of the skin, especially of his feet, 
became almost insupportable, and was invariably relieved by heating them 
at the fire. The coldness of winter sheets so affected him as to compel him 
to sleep in flannel drawers. Through the whole of these months of annoy- 
ance his health was good, and his liver acted with even more constancy than 
usual. In the following summer he suffered but little, but as the cool 
weather returned, the disease came with it, though somewhat mitigated in 
violence. In the succeeding winter it annoyed him still less, but although 
twenty years have elapsed, his lower extremities are still more or less 
affected by the cold weather, and especially by cold linen sheets. 



CHAPTER IX. 

ERYSIPELAS— INTRODUCTORY. 

If any one is incredulous as to the occurrence of sporadic cases of yellow 
fever, measles, or scarlatina, the history of erysipelas reasoned upon analo- 



INTERIOR VALLEY OF NORTH AMERICA. 619 

gically, is well fitted to remove his doubts. Whatever may be the uncer- 
tainty as to the former, there is none whatever in reference to the latter. 
All the world is familiar with its sporadic form, and within the last few 
years it has prevailed, to so great an extent in many localities, from the 
Lakes to the Grulf of Mexico, as to establish its epidemic character, if 
indeed its occasional epidemic prevalence in other countries had not already 
shown the same thing. Till within the last few years most of our physi- 
cians have, however, known it only as a sporadic disease. In proceeding to 
treat of it, I shall first consider it under the two heads suggested by these 
remarks. 



SECTION I. 

SPORADIC ERYSIPELAS. 

Symptoms.- — Sporadic erysipelas is generally limited to the skin and sub- 
cutaneous cellular tissue, extending now and then to the serous membranes, 
especially the cerebral. I do not recollect to have seen a case in which it 
invaded the mucous membranes. Common as it is in the face, it generally 
advances as far as the mucous membranes of the mouth and nostrils, and 
there abruptly stops. 

Erysipelatous inflammation, of a common kind, is easily distinguished 
from all the eruptions we have been studying in this, that it consists in a 
uniform inflammatory congestion of the skin, commencing at a point and 
spreading in one or all directions. The affected part is slightly raised, and 
generally presents a defined margin. Its color varies from a bright to a 
dark red, according to the vigor of circulation, and the age of the patient. 
In most cases the vessels may be relieved of their hypersemia by pressure, 
but the redness returns on removing the finger. Although the pain is 
seldom acute, there is an uncomfortable sense of heat and smarting, the in- 
fluence of which on the nervous system renders the patient irritable and 
restless. When intense, vesicles, and even large bullse, frequently form 
here and there upon the inflamed surface, and, in bad constitutions, may 
assume a gangrenous character. They sometimes break and form crusts. 
The trunk of the body is less liable to erysipelas than the extremities, in- 
cluding the head, which, of the whole, is oftenest attacked. Wherever it 
begins, it often takes the course of the distal end of the part, presenting a 
kind of analogy with deep-seated cellular or phlegmonous inflammation, 
which aims, so to speak, for the surface. The nearer, therefore, to the 
point to which erysipelas tends, the better is the prognosis. Thus, when it 
commences on the forearm, the case is better than when it begins about the 
shoulder; when it begins on the cheek, better than upon the neck or behind 
the ears. In both cases it is apt to take the direction of the nose, ceasing 
at the tip ; but sometimes it may pass off at the margin of the ears. Now 



620 THE PRINCIPAL DISEASES OF THE 

and then it commences on the back part of the head or neck, and advances 
forward on both sides to the mouth and nose. In cases which tend to a 
favorable termination the inflammation ceases behind while it is still ad- 
vancing forward with unabated activity. Its cessation is followed by an 
exfoliation of the cuticle in larger flakes than those cast off in measles and 
scarlatina. Although erysipelas generally has but one starting point, and 
spreads by what Mr. Hunter calls continuous sympathy, it sometimes arises 
in different places at the same time, or ceasing in one appears in another. 
Every physician has seen mild cases of erysipelas which commenced with- 
out previous indisposition ; but in general there is fever, with derangement 
of the digestive functions, for one or a few days, which may be compared with 
the eruptive fever of measles or scarlatina rather than of small-pox, seeing 
that it does not cease on the appearance of the cutaneous inflammation ; but 
often becomes more intense, and, in mild cases, supervenes after the affec- 
tion of the skin has spread to some extent, although none had preceded its 
outbreak. In vigorous constitutions this fever is always acute and inflam- 
matory ; but in those of an opposite kind, it frequently assumes an adynamic 
or typhous character. 

An immense majority of mankind pass their lives without experiencing 
an attack of the disease we have described; but there are a few who are 
liable to it, and suffer repeated attacks. It affects both sexes and persons 
of all ages; being more acute and amenable to treatment in youth and man- 
hood, most adynamic and dangerous in early infancy and old age. 

Our books abound in varieties, so called, of this disease. Let us look at 
a few of them. 

Traumatic Erysipelas. — All the world knows that wounds and injuries, 
which produce a solution of continuity, are sometimes followed by ery- 
sipelas. In hospitals it occurs from these causes much oftener than in 
private practice. The injury can only be regarded as an exciting cause. 
The erysipelas is only a sinister occurrence, increasing the danger from the 
injury, which in turn renders the erysipelas more unmanageable than idio- 
pathic cases occurring in the same constitution. It must be granted, how- 
ever, that a bad or broken down constitution is generally the predisposing 
cause of this attack ; as out of hospitals it seldom occurs to those who were 
in good health when the injury was inflicted. 

Infantile Erysipelas is always dangerous. In the cases which have fallen 
under my observation, I was not able to assign any remote cause. They 
had no connection with an epidemic of any kind, or with a prevailing puer- 
peral fever. The vital forces of the young infant sink rapidly under the 
reactive influence of the inflamed skin, as they would under a scald, which 
might be denominated a factitious erysipelas suddenly induced by an 
external cause. 

Phlegmonous Erysipelas. — The mildest cases of erysipelas may, in our 
vernacular phrase, be said to be only "skin deep." The swelling in such 



INTERIOR VALLEY OF NORTH AMERICA. 621 

is inconsiderable. The more violent dip into the subcutaneous cellular 
tissue, and a true cellulitis is superadded to the cutaneous erythema. This 
cellular inflammation presents two striking characteristics : first, it diffuses 
itself far and wide among and beneath the muscles, tendons, fasciae, and 
aponeuroses ; second, it terminates in early and extensive suppuration, under 
which, after great suffering, the patient may at last sink exhausted. 

(Edematous Erysipelas. — Whenever erysipelas spreads over parts which 
abound in loose cellular tissue, as the eyelids and scrotum, for example, a 
copious effusion of serum tumefies and renders them oedematous. A part 
in this condition lacks the hardness, tension, heat, redness, and pain which 
are present in diffuse inflammation of the cellular tissue. In vigorous con- 
stitutions this condition is unattended with any special danger; but in the 
aged or infirm may be followed by the death of the part. 

Causes. — Sporadic erysipelas has no specific cause. Of the state of the 
constitution which predisposes to the disease, it is impossible to speak very 
definitely. Those who are plethoric and irritable, without much firmness 
of fibre, as young females, are said to be liable ; aged persons in whom the 
circulation of the extremities has become languid, are subject to it; a tardy 
or imperfect convalescence from continued fevers, especially the eruptive, 
favors its occurrence ; breathing some kind of contaminated air, as that of 
a hospital, has the same effect; dissection wounds or other inoculations of 
morbid animal poisons ; the pathological condition produced by habitual in- 
temperance is, perhaps, the most frequent cause ; finally, disordered states 
of the liver, stomach, and bowels, and other internal organs, in some in- 
stances, appear to generate it as an external sympathetic affection. "We 
must not forget that all the pathological states here enumerated occur in 
multitudes without the supervention of this cutaneous inflammation ; and 
that a large proportion of cases are developed under the immediate influ- 
ence of some lesion of the skin, acting as an exciting cause, that is, raising 
an inflammation in that tissue, which, under a bad state of the constitution, 
assumes at once an erysipelatous character. Nor should we overlook the 
fact that in some cases which are supposed to be sympathetic, the disease 
may in fact commence in the skin, and become the cause of the internal 
disorders which are assumed to have occasioned it. Of this kind, perhaps, 
was the following: — 

Case of Erysipelas and Diarrhoea, alternating. — In the month of 
August, 1840, the late lamented Dr. Rhodes, of Zanesville, Ohio, took me 
to see one of his patients, a corpulent lady, seventy-four years of age. 
About two months before she had been seized with erysipelas on the front 
of her abdomen and thighs. In three weeks it nearly disappeared, and a 
diarrhoea came on, which proved obstinate, and continued for a fortnight, 
when it ceased, and the erysipelas returned, and in a week was as bad as in 
the first attack, soon after which it began to disappear, and the diarrhoea 
recurred. It was during this recurrence that I saw her. The affected skin 



622 THE PRINCIPAL DISEASES OF THE 

was free from inflammation, her tongue was dry, and she manifested both 
coma and delirium in a slight degree. The termination was fatal. 

Danger. — The dangers in this disease may be in part inferred from what 
has been said of the pathological conditions which predispose to it. A con- 
stitution impaired by intemperance, innutritious diet, foul air, or actual 
diseases, either acute or chronic, cannot hold out against the reactive influ- 
ence of an extensive cutaneous inflammation, which is itself apt to become 
gangrenous from a failure in the vital forces. Again, the spreading cha- 
racter of the disease is a source of danger. As long as its diffusion is in 
the cutaneous tissue, the danger is less; but if it dip deep into the inter- 
muscular system, fatal suppurations may occur; or, if it should attack the 
mucous membranes of the throat, a mortal (edematous laryngitis may super- 
vene; or should it penetrate the cranium and seize on the membranes of 
the brain, the patient may fall a victim of arachnitis, and this, from the 
great frequency of the disease on the face and head, is, above all others, the 
mode in which this malady proves fatal. 

This brief account of sporadic or occasional erysipelas seemed a necessary 
introduction to the study of the more important epidemic variety to which 
we must now apply, comprising the treatment of both forms under one 
head. 



SECTION II. 

EPIDEMIC ERYSIPELAS — CHRONOLOGY, GEOGRAPHY, AND CONTAGION. 

1. Chronology and Geography. — As far as I know or can learn, our In- 
terior Valley has never experienced but one epidemic visitation of erysipelas. 
Occurring at a late period, we might suppose that the materials for a full 
and instructive history could undoubtedly be found, but such is not the fact, 
for the accounts which have been published are few compared with the 
number of places attacked, and many of them are mere sketches. The 
desiderata left by them have been to some extent supplied by my notes of 
conversation with a number of physicians; but the whole fall short of what 
medical history demands. 

In seeking for the commencement of the epidemic, I said that in the year 
1826 it prevailed in Burlington, Vermont, on the shores of Lake Champlain ; 
in 1832 in Ogdensburg, on the St. Lawrence, where it still existed when I 
visited that place in 1847 ; and in 1835-6, in Preble County, Ohio. These 
invasions, especially the first, were so long before the general prevalence, 
that the propriety of connecting them with it may be doubted; I shall, 
however, regard them as its beginning. 

Considered in its totality, this epidemic was in fact a series or system of 
subepidemics which prevailed in limited and isolated neighborhoods. Its 
rise in each was generally by sporadic cases, gradually becoming more nume- 



INTERIOR YALLET OF NORTH AMERICA. 



623 



rous : and hence it is not easy to say in what season it actually commenced. 
Its duration was various in different places, and most of the accounts which 
have been given leave it uncertain at what time after the commencement it 
finally ceased. To make its chronology and geography more intelligible, I 
have thrown the whole into a tabular view; and included in it such refe- 
rences to the topographical part of this treatise, as will enable the reader to 
study the physical condition of most of the localities in which it prevailed. 



LOCAL EPIDEMIC: 



CHRONOLOGY. 


GEOGRAPHY. 


Topographical 
References. 








Vol. I. 


Year. 


Season or Month. 


North Lat. 


Locality. 


Page. 


1826, 


Winter, 


44° 40' 


Burlington, Vermont, .... 


420 


1832, 


Unknown, 


44° 45' 


Ogdensburg, New York, .... 


415 


1833, 


Spring, 




St. Clairsville, Ohio.* 




1836, 


January, 


39° 45' 


Preble Co., Ohio, 


297 


1841, 


Summer, 


45° 15' 


Eastern Township. Canada E., 


421-2 


1841-2, 


"Winter, 


44° 00' 


Middleburg, Vermont, .... 


a 


" 


it 


a n 


Moriah and Crown Point, New York, 


a 


1842, 


Spring, 


a a 


St. Albans, Vermont, .... 


it 


(< 


July, 


it it 


St. Johnsburg, " .... 


it 


" 


November, 


39° 00' 


Ripley Co., Indiana, 


305 


1842-3, 


"Winter, 


38° 50' 


St. Charles, Missouri, .... 


142 


" 


<< 


39° 00' 


Booneville, " .... 


168 


a 


it 


39° 30' 


Miami Valley, Ohio, 


297 


" 


a 


36° 34' 


New Madrid, Mo., 


132 


1843, 


November, 


43° 00' 


Wales and other townships of Erie 
Co., New York.- 


380 


1843-4, 


"Winter, 


45° 31' 


Montreal, Canada E . . . . . 


419 


u 


a 


43° 00' 


Milwaukie, "Wisconsin, .... 


340 


a 


a 


42° to 43° 


Various places "Western New York, 


380 to 406 


it 


1 1 


41° 50' 


Michigan City, Indiana, . . . 


343 


a 


a 


40° 30' 


^Bloomington, Illinois, .... 


322 


it 


it 


38° 03' 


Louisville Hospital, Kentucky, 


248 


it 


a 


35° 08' 


Memphis, Tennessee, .... 


133 


a 


a 


33° 00' 


Valley of Big Black, Mississippi, 


208 


it 


it 


32° 20' 


Jackson, " 


203 


it 


it 


a a 


Yicksburg and "Warrenton, " 


128 


it 


n 


43° 00' 


Counties of Genesee, Wyoming, 
and Alleghenv. New York, 


400 


1844, 


Spring, 


31° 30 7 


Grand Gulf and Port Gibson, Mis.. 


127, 207 


a 


" 


34° 36' 


Whitesbury, Alabama, .... 


225 


it 


.< 


35° 30 7 


Columbia, Tennessee, 


232 


it 


December, 


43° 00' 


Lima. Livingston Co., New York, 


394 


1845, 


February, 


34° 30' 


Courtland, Alabama, 


323 


a 


November, 


43° 00' 


Ontario Co., New York, .... 


400 


1845-6, 


"Winter, 


40° 00' 


Uniontown and Laurel Mount, Pa., 


268, 269 


tt 


a 


39° 15' 


Meigs Co., Ohio. 




1847, 


Spring, 


42° 30' 


Livingston Co., Michigan. 




1848-9, 


"Winter, 


39° 00' 

32° 20' 


Brown Co., Ohio. 

Near Yicksburg, Mississippi. 




it 


M 


29 3 57' 


New Orleans, La., Char. Hos., 


97 



* W. Jour. LouisTille, toI. vi. p. 52S. 

t Br. H. Jewett, Buffalo Med. Jour. vol. iii. pp. 262. 263 



624 THE PRINCIPAL DISEASES OF THE 

I might extend this catalogue of notices, but the additions would not 
change any of the conclusions deducible from it. To give the facts credi- 
bility, I have, in every instance, cited the proper authority.* Let us now 
see how they can be generalized, and what deductions can be logically 
drawn from them. 

1. We are not at liberty, perhaps, to date the beginning of this great 
epidemic constitution as far back as 1826, at Burlington ; yet I was assured 
by Dr. Sherman, of Ogdensburg, in the same region, that after it began 
in that place and its vicinity in 1832, it continued to prevail up to the time 
of my visit in 1847. We see also that it occurred in Ohio in 1835. But 
not to insist on these invasions, we have, in the table, ample evidence of 
its development in 1841. In 1842, it was extending, and by the close of 
1843, it had spread more widely still, so that the end of that year, and the 
beginning of 1844 (the winter of 1843—1), were the season of its greatest 
prevalence. But although from that winter the number of places attacked 
rapidly declined, there was still the next winter a decided prevalence ; for 
it continued or recurred in many localities, and was not extinct in 1849. 

2. When we compare the column of latitudes with that of dates, we per- 
ceive, with a few striking exceptions, that its march was from northeast to 
southwest, through fifteen degrees of latitude. In this respect it conformed 
(imperfectly) to the great typhous epidemic constitution of 1806-16, which 
was developed first in nearly the same region with the disease we are now 
considering, and advanced into the Southwest.")" The same line of march was 
also pursued, as we shall hereafter see, by the epidemic cholera of 1832, 
which traversed the Interior Valley from the estuary of the St. Lawrence 
to the delta of the Mississippi. We are scarcely at liberty to regard these 
coincidences as purely accidental. 

3. In every part of the very extended region through which it prevailed, 
there were towns and country settlements which remained exempt, while 
others, on every side, apparently under the same topographical, climatic, 
and social circumstances, remained exempt, showing the influence in this 
malady of the same law that governs the typhous fevers, epidemic cholera, 
measles, and scarlatina. 

4. In reference to climate as modifying the violence of the disease, it had 
no influence ; for, as we shall hereafter see, the disease was equally violent 
in the latitudes of 45°, 39°, and 32°, that is, on the banks of Lake Cham- 
plain, the Ohio, and the Lower Mississippi. 

* [Several pages of MS., containing these citations, are wanting, fragments only having heen placed 
in the editor's hands. Prom these fragments it also appears that the author had the materials for 
chronological and geographical notices of the occurrence of local epidemics of the disease under con- 
sideration, at places on this continent heyond the limits of the Interior Valley, similar to those pre- 
sented in the table. A memorandum states that such an erysipelatous invasion " commenced on the 
northern part of New Hampshire, north latitude 45°, in the year 1841, and made its way down the 
valley of the Connecticut River, and that it prevailed in various places east of the mountains, from that 
in which it originated, to the southern part of Virginia, which it reached in the winter of 1844-5."] 

t See Book II. Part III. Ch. I. 



INTERIOR VALLEY OF NORTH AMERICA. 625 

5. Neither had the mineralogical and topographical character of the 
country any effect, as may be seen by a reference to the descriptions of the 
places where it prevailed, which shows that its victims dwelt upon rocks of 
every kind — on granite, limestone, sandstone, slate, and clay, and of every 
geological age, from the primitive to the alluvial; also, that it occurred on 
mountain slopes, low hills, and flat-bottom lands. 

6. As to density of population, we may say, on the whole, that it was a 
rural, much more than an urban disease, and that most of its localities had 
been more recently settled than many others, which it passed over. In the 
cities of Quebec, Montreal, Buffalo, Pittsburg, Cleveland, Cincinnati, 
Louisville, St. Louis, and New Orleans, it was scarcely known, even as a 
subepidemic, except in their hospitals, and there it never prevailed with a 
violence approaching to that which it displayed in the country. 

7. Referring to its connection with the seasons, we may say, that it pre- 
vailed throughout the whole, though much more in winter and spring 
than in summer and autumn, generally making its appearance late in 
November or in December; but, in some instances, in the spring. It is 
to be regretted, however, that most of the histories on these points are 
exceedingly imperfect. 

8. This is not the place to discuss the question of its contagiousness ; but 
as a deduction from the facts before us, it may be affirmed that in many of 
the places which have been named, it did not begin from contagion; for its 
outbreak, nearly at the same time, in various secluded country settlements 
and villages, scattered over ten degrees of latitude, and as many of longi- 
tude, does not allow us to believe in a contagious introduction, unless the 
fact were established in each case by positive proof, which has not been 
done in any one. 

II. Contagion. — The conclusion which has just been drawn from the 
chronological and topographical history of epidemic erysipelas does not pre- 
clude the inquiry whether it ever propagated itself by contagion ; for we 
have already seen that the typhous fevers sometimes originate from local 
causes, and then propagate themselves in that manner. Now, what are the 
evidences of contagious propagation ? 

Dr. Sutton,* on the approach of the epidemic, was a disbeliever in conta- 
gion, but experience led him to, if it did not confirm, .the opposite conclu- 
sion. His principal facts will be found in the following condensed account 
of the disease, in a large family connection, which he was called to attend 
at an early period of the epidemic. The head of the family was John 
Buffington, who had three married sons, G., W., and F., and a son-in-law, 
Mr. Wilman. The wife of G-. B. had a sister married to John Winscott. 

On the 20th of June, 1843, Dr. S. was called to see G-. B., living on the 
highlands, a little back of the Ohio River, and affected with the epidemic. 

* West. Lancet, vol. ii. p. 308. 

vol. ii. 40 



626 THE PRINCIPAL DISEASES OP THE 

He was nearly restored by the end of the month. On the 26th he was 
called to see Mrs. Winscott, sister-in-law of B., who had been with him part 
of his illness. She had been indisposed for several days, and, passing regu- 
larly through the disease, was nearly well by the 2d of July. On the 29th 
of June, Mrs. B., the wife and sister, was seized with the same malady, 
and recovered in about a week. Mr. and Mrs. B. were, at the time, living 
in the family of Mr. Huffman, eight in number, and within a week after 
Mr. B.'s recovery, seven of them were attacked with the epidemic, in a mild 
degree, and all recovered. On the 5th of July, Dr. Sutton was called to 
see John Winscott, the husband of the woman mentioned above. This 
patient suffered severely, but was nearly well by the 14th. Mr. W. had 
three children, who, during his illness, had " swelling of the glands of the 
throat and neck, connected with fever,'' but without any affection of the 
skin. On the 10th, the Doctor was called to Mrs. F. B., who had been for 
some time in bad health, and on the 28th she died. Dr. Sutton does not 
tell us whether any intercourse had taken place between this patient and 
the first of the same name; but I refer to it to add that, during her illness, 
and soon afterwards, her husband and two of three children suffered attacks, 
which were generally of a mild character. On the day of her death, he 
was called to see Mrs. Wilinan, her sister-in-law, in whose family there 
were seven other cases within a week thereafter. The family of W. B. 
numbered eight, of which but one escaped. The family of J. B., the father, 
consisted of four, all of whom had attacks. As these families occupied dif- 
ferent houses, the disease cannot be regarded as of domestic origin. Ac- 
cording to Dr. Sutton, it was, in a particular quarter of his range of prac- 
tice, almost " confined to the Bumngton family and those who were in con- 
stant attendance upon them." 

Although these cases seemed to indicate contagion, the cautious mind of 
Dr. Sutton did not come fully up to that conclusion j for, while the disease 
was still prevailing, he saw " every member of a family, eight in number, 
attacked in succession with bilious remitting fever." Still further, the con- 
sanguinity existing among the greater portion of these patients, favors the 
idea of a family predisposition, giving to an atmospheric remote cause a 
greater effect on them than on others. Finally, we are told by Dr. Sutton 
that from the beginning the people believed in the contagiousness of the 
disease, and we may suppose, therefore, that terror spreading through a 
family connection, from seeing one of their number stricken down, might 
become a powerful exciting cause. On the whole, the facts furnished by 
Dr. Sutton do not, I think, establish the existence of contagion, but render 
it highly probable. 

Drs. Hall and Dexter* lean to the opinion that the epidemic was contagious. 
As to its mode of spreading, they say it was irregular and erratic; and in 
different localities it was strikingly modified in its symptoms. One of their 

* American Journal for June, 1844. 



INTERIOR VALLEY OF NORTH AMERICA. 627 

correspondents, Dr. Barney, saw all the members of a family of eight 
attacked at the same time. These facts seem not to favor the theory of 
contagion. 

On this subject, Dr. Jewett, who treated the disease in Cayuga County, 
New York, says, " As to its contagious character, I will only say, that at- 
tendants, and those most exposed to the sick-room, are very liable to it. In 
some instances, whole families have been successively attacked, as have do- 
mestics also, some of them after returning to their homes at a distance for 
the purpose of avoiding the danger.* 

At Bloomington, Illioois, where it prevailed extensively, Dr. Henry and 
Dr. Colburn saw no proof s of contagion. Dr. Henry observed that when it 
began in one of the insulated settlements of that prairie country, which are 
always in and around the groves, it generally attacked all the families ; yet 
he could not perceive that a contagious propagation existed. Dr. Colburn 
saw many who waited on the sick escape, and saw others taken down who 
had never seen a patient with it. 

In Boonville, Mo., where it prevailed severely, Dr. Thomas saw no facts 
proving it contagious ; but Dr. Hartt made the following observation : the 
wife of Dr. M. was seized, after the disease had prevailed for a while spora- 
dically ; while her husband was nursing her, he sickened with it. Mrs. 
O'B., the mother of the former, came from eighteen miles in the country, 
and engaged in nursing both, during which she was taken down. Dr. Hartt 
was employed to attend her, and sickened with the same malady • a fortnight 
after his seizure, his daughter was attacked; two days afterwards his son; 
and lastly, his negro boy. It must, I think, be admitted, that these seven 
successive cases, occurring in persons belonging to four families distinct in 
blood, give strong support to the theory of contagion ; yet Dr. Hartt saw 
cases in the country that certainly had not arisen from any communication 
with others. 

The late Dr. Dorsey of Yazoo City, Mississippi, gave me the following 
facts : Mrs. W. visited Tchula where the disease prevailed, and two weeks 
afterwards her infant was attacked ; while it was yet ill she herself was 
seized ; her husband likewise had a slight attack ; her nephew, a lad living 
with them, was then taken down ; her sister, another member of her family, 
who had also visited Tchula, next sickened and died ; a female friend came 
twenty miles from the country to visit the family, returned home and fell a 
victim to the same malady ; a negress who was nursing them was also seized ; 
then another who belonged to the family of the nurse was taken down ; then 
the mistress of the slaves and three of her children. Several of these attacks 
were slight, yet their diagnosis was well marked ; and one can scarcely avoid 
the conclusion that there was contagious propagation. 

From Drs. Shanks and Frazier, practising in partnership, I received the 

* Boston Med. and Surg. Jour. 



628 THE PRINCIPAL DISEASES OP THE 

following statement: On the 20th of April, 1844, a man, W., without 
having been exposed to contagion, was seized with the disease. On the 5th 
of May, another man, R., in the same house, who had received a wound in 
the right arm two weeks before, which, however, had healed, was attacked 
in the injured part. On the 20th, his wife, who was waiting on him, and 
assisted dressing his suppurating arm, was seized with the disease in her thumb, 
where there was a slight sore. On the 22d and 24th, their two daughters, 
aged twelve and fourteen years were attacked. The first patient, W., was 
removed to his brother's, and a girl visiting in the family was attacked and 
died. On the 10th of May, the brother sickened with the same disease 
and died. On the 27th of May, Dr. Shanks was himself taken down. 

These were all the developed cases which Drs. Shanks and Frazier were 
called to treat, and every patient, except the first, had been with those who 
labored under the disease, but many others who visited them continued 
healthy. These cases aflbrd strong evidence of contagion ; yet it is subject 
to this defalcation, that at the time when they occurred, a great number of 
persons, as Drs. Shanks and Frazier informed me, had slight sore throats. 

Dr. Capshaw* has given us the following* facts : On the 20th of March, 
1844, a negro woman who had lately come into the service of Mrs. E., of 
Whitesburg, was attacked j he administered the medicines to her, and about 
the 1st of April was himself taken down. On the seventh day of his dis- 
ease he was visited by two children of Mr. H., who also visited the negress 
first attacked, and a week afterwards (April 14th), they were both attacked. 
On the 20th, W., a mulatto boy who spent much of his time in the house 
of Mr. H., was seized with the disease ; on the 28th his brother and a ne- 
gress, both of whom worked in the family, were attacked ; and on the 29th, 
Mr. C, residing with Mr. H., was seized. The last four had been constantly 
with the two sick children. 

From Dr. Paxton of Knoxville, where in 1844-5, the epidemic prevailed 
tp a limited extent, I got the following statement of what occurred in the 
family of a widow, who had one son, two daughters, and a girl who was an 
inmate of the family. One of the daughters watched for a night with 
an erysipelatous patient, and soon afterwards sickened with the same disease, 
then her mother, sister, and the little girl, all of whom slept in the same 
room with her, were seized ; the son, who lodged in another room, but waited 
on them, also took the disease; finally a married daughter, who lived in a 
different house, spent two nights in nursing the family, which was followed 
by an attack. 

Dr. Robardsf of Columbia, Tennessee, makes the following statement. 
The first case which occurred in that town was in winter, and the room in 
which the patient was confined was kept close. " Out of the number of 
persons that waited on that case, at least eight-tenths took the disease, two- 

* West. Jour. (Louisville) 2d series, vol. iv. p. 1. 
t West. Jour. (Louisville) vol. iv. p. 288, 



INTERIOR VALLEY OF NORTH AMERICA. 629 

thirds of whom died." A suspicion of its contagious character having arisen, 
" precautions were used," and no more manifestations of contagion occurred. 

Dr. Keller of North Alabama, had twenty-nine cases on one plantation. 
It was supposed to have been introduced by a negro from another farm. All 
who waited on the sick were attacked. At length sheds were erected in a 
neighboring grove, to which all the negroes that could be spared from the 
sick, were removed. No case occurred there. " The old cabins were 
thoroughly renovated and washed with lime," and the people brought back 
to them in ten days, after which but two cases occurred. 

Dr. Montgomery has given us the following facts. A young woman who 
was on a visit to her friends, when the epidemic appeared among them, 
after attending on several of the cases returned home, a distance of one 
hundred and fifty miles. Four or five days after reaching her father's 
house, she was taken down with a violent attack, and several of the family 
with some of the neighbors, who waited on her, sickened with the same 
disease, of whom three died. A negro woman was sold off a plantation 
where the disease prevailed, and taken thirty miles into a very healthy 
settlement. She was perfectly well for six days after reaching there, when 
she was seized with the disease and died. Several of the negroes who 
waited on her were attacked with the same malady, but it spread no further. 
Dr. Montgomery after narrating these declares that many other events of a 
similar kind occurred. 

The following facts relate to the disease at Grand Gulf and Port Gibson, 
ten miles apart. The disease was prevailing in the former, when Dr. More- 
head was called from the latter, to the case of a man down with it. In 
making an application to the throat of his patient, some of the secretions of 
the mouth fell on an abraded spot on one of his fingers, it soon began to 
inflame, and be returned home to die of the disease. Dr. Harper, one of 
my informants, was his principal physician as to closeness of attention, 
and in a few days after beginning he was seized. Two men who waited on 
those patients suffered attacks j and the wife of one of the attending physi- 
cians, Dr. Abbey, without having had any communication with the sick, 
suffered an attack, though her husband escaped. One of the cases at Mem- 
phis, and that of Dr. Morehead, seem to present us with inoculation of the 
disease ; yet in the paper of Drs. Hall and Dexter, we are told that the 
inflammation commenced in an abraded spot, in the palm of the hand of a 
farmer living secluded in a deep forest, and we must not forget, moreover, 
how often sporadic erysipelas begins in some wounded or unsound spot. 

The facts presented in this section seem to me to place epidemic erysipelas 
in the same category with the typhous fevers. Originating sometimes, if 
not always, from some other cause than contagion, yet in many instances 
spreading by that means. 



630 THE PRINCIPAL DISEASES OF THE 

SECTION III. 

EPIDEMIC ERYSIPELAS, CONTINUED : — SYMPTOMS. 

I. General Views. — It is far less difficult to give a readable descrip- 
tion of the true eruptive fevers, or 'even of sporadic erysipelas, than of the 
epidemic variety. This results from the greater regularity and uniformity 
of the symptoms which characterize those fevers, and the greater simplicity 
and more external seat of casual erysipelas. 

Before entering on a detail of symptoms, a few general views may be 
advantageously presented. 1. All the observers have seen cases in which 
the local affection distinctly preceded the constitutional. In these instances 
the inflammation generally (not always) commenced in some spot or point 
which had suffered mechanical injury. In the greater number of cases the 
constitutional and local disorders began at the same time ; but in many the 
former distinctly preceded the latter. Here then is diversity at the very 
outset. 2. Those who have seen and studied sporadic erysipelas, only think 
of it as a disease invariably affecting the skin ; liable to dip deep beneath 
it, or to be translated or to spread to some internal tissue, still being essen- 
tially a cutaneous affection; but in the late epidemic, the skin in a majority 
of the cases escaped the disease. 3. Instead of that tissue, the mucous 
membrane of the mouth, nares, throat, and larynx, was the constant or chief 
seat of the local affection. Affections of the lungs and brain, and in par- 
turient women the peritoneum or utero-vaginal membrane of the skin, the 
intermuscular cellular tissue, the lymphatic ganglia, and various other parts, 
might, in different cases, exist, but that of the pharyngeal mucous membrane 
was never absent. 4. In different places, and in the same place, even in the 
same family, some cases were so slight as scarcely to demand medical treat- 
ment, while others proved rapidly fatal, in despite of every curative effort. 
5. In all cases, when fully developed, both fever and inflammation were 
present. In the typhous affections there is fever with inflammation or sim- 
ple hyperemia : in this form of erysipelas, the hypersemia was generally 
active, and copious suppuration, sloughing, or gangrene, was a common 
event. Having taken these general views we must proceed to details. 

II. Cold or Forming Stage. — The duration of this stadium of the fever 
varied from a few hours to several days. In the former case a severe chill, 
with but few antecedent symptoms, was followed by violent fever ; in the latter, 
the patient felt unwell,* with languor, creeping chills, loss of appetite, costive- 
ness, a foul tongue, sometimes an irritable stomach, pain in his head, neck, 
back, and limbs, or in particular joints; and very often a slight sore throat. 
Sooner or later, the coldness or rigor deepened into a severe and often pro- 

* Several of the historians of this epidemic have expressed this condition by the word malaise. Now, 
it is very right to import knowledge from France, but quite unnecessary to adopt French words, espe- 
cially when, as in the present case, we have a most expressive vernacular term, used in its primary 
sense, while the French word is used figuratively. 



INTERIOR VALLEY OP NORTH AMERICA. 631 

tracted chill, followed by reaction and fever. The cold fit was never re- 
peated, although, in some cases, the fever displayed a remittent type. There 
was a third aspect of the forming stage, in which there was general cold- 
ness, with a damp skin, a sense of sinking and oppression, a frequent and 
feeble pulse, and great incapacity of the system for reaction j a state similar 
to that in the malignant periodical and continued fevers. 

It is to be regretted that those who had ample opportunities of seeing this 
fever have said but little on its forming stage. I have included irritability 
of the stomach among its phenomena, yet most of its historians have said 
nothing on that subject. On the whole, its first stage bears a greater resem- 
blance to the forming stage of the phlegmasise than the continued or periodi- 
cal fevers. 

III. Hot Stage. — In many cases occasional chilliness continued to recur 
after febrile reaction was fully established. In some the general heat was 
not well developed, the feet remaining cold, and in some a profuse perspira- 
tion occurred, while the other symptoms indicated continuance of the fever. 
The majority, however, presented full fever heat, great thirst, a rapid and 
bounding yet compressible pulse, which, with a slight morning abatement, 
continued day after day. In persons naturally feeble or rendered infirm by 
previous disease, the' pulse was often weak. In none, or next to none, was 
it tense or a pulse of power. The tongue was heavily furred, but in general 
had not the whiteness which characterizes the phlegmasiae ; on the contrary, 
at an early period of the fever the fur began to change, especially in the 
longitudinal centre of the organ, to the brownish hue, which in a short time 
overspread the whole surface. 

The aches and pains of the head, back, and limbs, present in the forming 
stage, become still more intense in the reactive, and were often especially 
violent in parts over which the characteristic erythema presently appeared. 

It is not possible to speak with certainty of the state of the blood. Many 
physicians did not draw any, and those who did have in general neglected 
to tell us whether it was buffy. Dr. Dawson mentions one case in which 
the blood on the third bleeding was sizy, and Dr. Henry, of Illinois, in- 
formed me that he bled in nearly all his cases and found the blood uniformly 
buffed. On the whole, however, we may believe that those who drew blood, 
would have reported it sizy, if they had found it so ; and that their silence 
is an evidence, that in general it was not in a state of hyperinosis. 

IV. Inflammation. — 1. The surface affection in this disease appeared in 
every degree of violence from an early fading erythema to a disorganizing 
erysipelatous inflammation. The throat was its chosen seat. In many 
cases the very first symptom was a feeling of soreness with some difficulty 
in swallowing ; but more commonly other symptoms of indisposition con- 
stituting the first stage of fever, appeared at the same time ; and in some 
preceded the auginose affection, which was developed with the hot stage. 
The nosological terms, pharyngitis, laryngitis, tonsillitis, and glossitis, are 



632 THE PRINCIPAL DISEASES OP THE 

scarcely sufficient to represent the varieties of this inflammation. In the 
vigorous, when the fever was acute, the color of the mucous membrane was 
a bright red, but in general a darker hue prevailed. In many cases there 
were spots of adherent mucus, and in some patches of imperfect coagulating 
lymph. The ash-colored eschars and ulcers so frequent in scarlatina, were 
rarely observed \ and suppuration of the tonsils so common in ordinary in- 
flammation, was a rare event. The swelling or thickening of the membrane 
from congestion was decided, but early infiltration of serum between its 
laminae and into the submucous cellular tissue, greatly added to the diffi- 
culties and danger of those cases in which the epiglottis and rima glottidis 
were affected. In extending downwards, the inflammation did not in gene- 
ral take the course of the alimentary membrane, but the respiratory, gene- 
rating an erysipelatous laryngitis, treacheitis, bronchitis, pneumonitis, or 
simple congestion, with its characteristic symptoms and physical signs. Of 
all the tegumentary extensions of the disease, this was the most dangerous. 
The upward and forward extension was into the mouth and nasal passages 
and sinuses. The inflammation of the buccal and lingual membrane was 
scarcely ever initial, but generally consequent on that of the throat. In 
many cases the tongue remained unaffected, except in the secretions of its 
surface, till the disease had existed for some time, and in others it escaped 
entirely, was indeed pale and flabby. In cases of glossitis involving the 
submucous and intermuscular tissue, the inflammation undoubtedly often 
descended from the surface, but Dr. Dawson has described a case in which 
the membrane showed no signs of hypersemia till the tongue had swollen, 
stiffened, and become painful, showing a deep commencement and an out- 
ward spread of the inflammation. The swelling of the organ was now and 
then so great as to cause its projection beyond the lips, and to render both 
speech and swallowing nearly impracticable. The early morbid secretions 
of the membrane assumed a dark color, further secretion frequently ceased, 
and the surface dried ; at the same time, the blood lost much of its arterial 
hue, and the organ put on the aspect which suggested for the disease the 
revolting epithet of " black-tongue." When the spreading inflammation 
entered the posterior nares, the swollen membrane compelled the patient to 
breathe through his mouth, thus contributing to its dry and uncomfortable 
condition. In advancing, it turned aside into the frontal, maxillary, and 
other sinuses of the face, raising in and over them severe achings and a dis- 
tressing sense of oppression. Finally, from the anterior nares it ascended 
the nasal ducts and attacked the eyes. 

2. In many cases the inflammation spontaneously ceased, was arrested by 
art, or proved fatal by the lesion of respiration, while it was still limited to the 
mucous surfaces ; but more commonly it advanced from the mouth, th.e nostrils, 
or the lachrymal ducts, upon the skin. In some cases it was limited to one 
side of the face and head; but much oftener overspread both. Now and 
then it descended upon the trunk or the arms ; leaving the parts above com- 



INTERIOR VALLEY OF NORTH AMERICA. 633 

paratively uninjured ; still its favorite field was the integuments of the 
bead and face and neck, which were often enormously swollen. The swell- 
ing depended in part on sanguineous congestion of the dermoid and subjacent 
areolar tissue j but still more on serous, fibrinous, or purulent effusions. 

True to the erysipelatous character, as the inflammation advanced it 
abated in the parts previously affected. To borrow an illustration from 
war, it moved like an invading army that does not leave garrisoned forts 
behind it. Thus, in numerous cases, almost as soon as the inflammation 
appeared on the face, its cessation in the mucous membrane was declared by 
an abatement of laryngeal dyspnoea, cough, hoarseness, dysphagia, pain, 
soreness on pressure, swelling, and redness of the throat. This signal 
relief was not, however, always permanent; for cases were met with by 
several observers, in which the cutaneous inflammation ceased, and the 
mucous returned in the parts first affected; and this alternation, known to 
happen in sporadic erysipelas, was sometimes repeated in the same patient. 

But the cutaneous erythema was not always an extension of the mucous; 
for in many cases after the latter had continued for a few days, the former 
would commence on one ear or cheek, the side of the neck, or somewhere 
else about the head or face, and immediately begin to spread. 

The local affection, moreover, did not always begin in the mucous mem- 
branes. In many instances it commenced like sporadic erysipelas in the 
skin, whence it entered the aerial passages, in some cases, in others it arose 
in them subsequently to its origin in the integument, and in a few patients 
the throat remained unaffected to the last. When no local injury, scratch, 
puncture, abrasion, or recently cured inflammation, existed on any part of 
the body, the erythema generally commenced on one of the ears or cheeks, 
the point of the nose, the angle of the eye, or the side of the neck, and 
proceeded to envelop the whole head and face; but if there were an infirm 
spot on the trunk or extremities, it generally began there ; in many cases, 
moreover, having its commencement in the extremity of the finger or toe, 
which had not been injured. In some patients it overspread the skin by 
continuous progress, in others it ceased in one part and broke out in another; 
in others still, it appeared in different places at the same time. Dr. 
Capshaw saw it commence on the right instep, ascend to the point of the 
scapula, cross over to the left side, and descend to the ankle. Dr. Dawson 
saw it begin on the ear and overspread the whole body. 

3. The appearance of the eruption was, on the whole, that of sporadic ery- 
sipelas. In the beginning, especially in vigorous subjects, of a red color; 
but in the feeble, and in all, after it had existed for awhile, of a dark and 
often livid hue. The vesicles were sometimes very minute, and contained a 
transparent fluid, which gave them a crystalline appearance; in other 
cases they were larger, and filled with a sanious fluid of a straw or dark 
muddy color. In a few cases, large vesicles or blebs arose without any 
erythema; in some instances, wheals, resembling those of urticaria, ap- 



634 THE PRINCIPAL DISEASES OF THE 

peared, and in some, to be hereafter considered, the efflorescence resembled 
that of scarlatina. In some patients, cutaneous sloughing led to the for- 
mation of superficial ulcers, and in all, or nearly all, there was an exfolia- 
tion of the cuticle. A smarting pain was always present, and occasionally 
there was a sense of formication. 

4. The submucous and subcutaneous areolar tissue was ravaged by the dis- 
ease in almost every violent case. Severe and tensive pain, swelling, and heat, 
indicated the development, primary or secondary, of this phlegmonous inflam- 
mation. It was very often seated beneath that spot of the skin on which 
the erythema first appeared, and in many cases seemed to commence before 
the cutaneous affection. Rapid and copious effusions ensued. These, in the 
milder cases, and the beginning of all, were serous ; but very soon that 
fluid was rendered turbid with flakes of fibrine, but little prone to unite 
the surrounding tissues; an early secretion of pus of an abnormal cha- 
racter added a new and more deleterious ingredient to the compound; in 
some instances more or less blood mingled with the fluid mass, and finally, 
dead and detached portions of areolar tissue contributed to the heterologous 
accumulation, which was not confined to a cavity by walls of false mem- 
brane, but diffused itself beneath the integuments, and among the muscles, 
tendons, arterial trunks, and nerves. In some cases, large portions of 
muscle were said to slough away in this putrid sanies, which was so acrid 
that it would inflame the sound skin over which it was permitted to flow, 
and, according to Drs. Hall and Dexter, so constituted chemically, " that 
the hardest steel was directly penetrated by it as by nitric acid." In other 
cases, instead of this most abnormal suppuration, the parts lost their vitality 
and became gangrenous. 

5. The salivary glands and lymphatic ganglia suffered not less than the 
areolar tissue. The sublingual, buccal, and parotids, in whole or in part, 
never escaped when the mouth or throat was affected. In some cases they 
became the seat of pain and swelling, even before the mucous membrane or 
the skin. Now and then they were the seats of suppuration, or became 
involved in that of the surrounding areolar tissue. When the disease com- 
menced on a limb, the lymphatics extending to the neck, axilla, or groin, 
often became inflamed. In numerous instances the ganglia of the neck 
were seriously swollen and painful, quite as early as the mucous membrane 
was affected, and sometimes before. They were often involved in foul 
suppurations, and those of the axilla and groins did not wholly escape the 
disorganizing process. 

6. Deep-seated pains and achings have been already mentioned as cha- 
racteristic of this disease. The head, the trunk, and the limbs, — all parts 
of the body, indeed, where the white fibrous tissue, whether under the 
names of periosteum, perichondrium, or pericranium, is found, were the seats 
of these pains, which, from their frequent change of place, and the absence 
of external signs of inflammation, were called neuralgic. This view was 



INTERIOR VALLEY OF NORTH AMERICA. 635 

often correct; yet, in many instances, a destructive periostitis did occur, 
separating the muscles from the membrane, and detaching it from the bone. 
In other cases the inflammation of the surface descended to the bony struc- 
ture. In both the result was a putrilage, which, if not freely evacuated by 
art, diffused itself extensively among the tissues. In some cases the bone 
itself yielded to the morbid action, and a case fell under the observation of 
Dr. Jewett, as reported by Dr. Hall, in which "a large portion of the ex- 
ternal table of the skull" exfoliated. 

7. Closely connected with this was the development of meningeal inflam- 
mation in the brain, so common and so much dreaded in erysipelas, both 
sporadic and epidemic. The histories of this invasion do not indicate that 
such inflammation was frequent. In some cases it no doubt began within 
the cranium, but in others it entered from without, permeating, as it were, 
the bony structure, or passing through the foramina provided for the blood- 
vessels. The cerebral complication was marked by vertigo, headache, de- 
lirium of a low kind, subsultus tendinum, and deep coma. These symp- 
toms do not, it is true, necessarily imply inflammation; but from the 
general character of the epidemic, we may infer its existence. Unfortu- 
nately for the interests of pathology, not a dissection of the brain, as far as 
I can find, was made. 

8. The extension of the inflammation from the throat to the bronchial 
tubes has been already mentioned. It did not, however, limit itself to them, 
but attacked the air-cells, the connecting areolar tissue, and the pleura. 
Hence pneumonia and pleurisy were common occurrences; and declared 
themselves by the usual symptoms and physical signs during life. 

The affection of the lungs and pleura was not always secondary to inflam- 
mation of the throat or skin, but on the contrary it frequently commenced 
with the fever, and in some cases occurred without either mucous or cuta- 
neous erythema; yet, as such cases were mingled with others io which the 
pulmonary affection was consequent on the pharyngeal or dermoid, they 
were very properly regarded as the offspring of the same cause. It was ob- 
served that when pneumonia or pleurisy existed, either as a primary or se- 
condary affection, the blood was sizy ; yet the loss of a few ounces from a 
large orifice, according to Dr. Sutton, produced syncope. In Canada, Dr. 
Colby encountered the same erysipelatous pneumonia, but in that higher 
latitude, copious and repeated venesection, affording sizy blood, was well 
borne. The involvement of the lungs was not confined to the higher lati- 
tudes, for Dr. Wharton and Dr. Tuck witnessed it on the Lower Mississippi. 

9. The inflammation, judging by the symptoms, rarely invaded the 
mucous membrane of the stomach. A certain degree of gastric irritability 
existed in many cases, but vomiting, anguish, tenderness under pressure, 
limited to the epigastrium, and other reliable signs of gastritis, were not 
common, though several physicians occasionally met with such cases. The 
symptoms of mucous enteritis were still rarer. The bowels were easily 



636 THE PRINCIPAL DISEASES OF THE 

acted on by cathartics, but diarrhoea scarcely ever occurred. The perito- 
neum in men and non-parturient women was obnoxious to the inflammation, 
but not in as high a degree as the pleura. Pregnant and especially lying- 
in females were, however, peculiarly liable, and the most fatal cases were 
the puerperal. I say nothing, however, on the history of these cases here, 
as they can be best studied under the head of Puerperal Fever. 



SECTION IV. 

EPIDEMIC ERYSIPELAS, CONTINUED. — PATHOLOGY. 

I. A mild and limited erysipelatous inflammation may exist without 
fever; but whenever the topical affection is severe, that constitutional 
disease is present. When the inflammation occurs first, it is said to pro- 
duce the fever ; and this might be admitted, if we did not observe that in 
numerous cases the latter arises with the former, or quite as often distinctly 
precedes it. I suppose the truth to be, that the local and constitutional 
affections stand in the same relation to each other, as we have endeavored 
to show they do in autumnal, yellow, typhous, and the exanthematous 
fevers; and as in each of them we have recognized a peculiar febrile and 
inflammatory type or diathesis, so we should recognize as a peculiar, or ery- 
sipelatous diathesis, the disease we are now studying. 

When the disease appears as an epidemic, it depends on some undiscovered 
cause. When sporadic it depends on different equally unknown causes, in 
all of which it may be compared with the typhous fevers. 

The peculiarities of erysipelatous inflammation are chiefly the following. 

1. Its disposition to spread over the cutaneous, mucous, and serous sur- 
faces, especially the first, in which it generally takes some definite direc- 
tion, and in many cases cannot be arrested j but continues to the extremity 
of the part on which it originated, and expires on reaching it. Thus be- 
ginning on the arm, it may pass off at the extremities of the fingers ; or on the 
side of the neck or face, it may cease on reaching the point of the nose or 
ear. On the other hand, commencing on one of the limbs it may take the 
direction of the trunk of the body. In doing this, it sometimes crosses the 
mesian line, and travelling in the reverse direction on the opposite side, may 
reach a point corresponding to that at which it commenced. We may cer- 
tainly admit the reality of this peculiarity without being able to explain it. 

2. Erysipelatous inflammation is eminently destructive of the tissues in 
which it occurs. In this ready yielding of the tissues we may, I think, 
trace a previous lesion of the vital properties, for the characteristics of true 
inflammation frequently bear no proportion to the disorganization which 
they produce. A part of these ravages depend on a great secretion of serum 
or a serous fluid. Thus the skin becomes covered with vesicles, and even 
blebs containing opaque fluid; and the subcutaneous areolar tissue, as that 



INTERIOR VALLEY OF NORTH AMERICA. 637 

of the face or the larynx, becomes highly edematous. This serum often 
contains the fibrine of the blood ; but not in sufficient quantities, or of sucli 
a true inflammatory kind, as to occasion adhesions. An early and often 
profuse secretion of pus may occur, but it is generally thin and often ichor- 
ous, and not being confined by the barriers which ordinary inflammation 
sets up, spreads abroad in the tissues and contributes to their disinte- 
gration. 

3. The vital forces of the affected parts are apt to fail, the congestion 
meanwhile continuing, and giving to the parts the dark or sublivid aspect 
which indicates a stasis of the blood in the capillary vessels. A tendency 
to gangrene, and the death of the part, is indeed a frequent event in this 
variety of inflammation ; and sometimes manifests itself without its pre- 
vious occurrence in a well-developed form. 

II. The fever in erysipelas harmonizes well with the inflammation. In 
the most acute cases the pulse scarcely ever reaches the strength and hard- 
ness which are characteristic of the phlegmasise ; the drawn blood very 
seldom exhibits a state of hyperinosis; in many cases which seem to demand 
bleeding the forces of the circulation give way under a small abstraction ; 
in others the fever is never developed with intensity, and at an early 
period, although the inflammation may be still spreading or at least 
show no signs of resolution, the physician is restrained from further deple- 
tion, or the use of any debilitating agents, and obliged to resort to tonics 
and stimulants. As still. further characterizing both the fever and inflam- 
mation, we may refer to the great tendency of the latter to leave one part 
of a tissue and appear on another, or to abandon one tissue and attack 
another. Finally the exhalation from the inflamed part or from the gene- 
ral system, is sometimes a real contagion, raising the same form of disease 
in those exposed to it. With these facts before us, we cannot, I think, deny 
that the disease now under consideration has a pathology of its own; and 
although its diathesis be not as strongly marked as that of small-pox, it is 
at least as well expressed as that of the autumnal or typhous fevers. 

Its complication with those and many other forms of fever is a well-known 
fact. Thus, as we shall hereafter see, it is often joined with puerperal peri- 
tonitis, and in some parts of our Valley has been signally modified by 
scarlatina; when it occurs during the reign of the true phlegmasia it always 
puts on a more inflammatory character, while if a typhous epidemic consti- 
tution should prevail, it assumes an adynamic character j and finally when 
it occurs in malarial regions, the fever sometimes assumes a remittent 
type ; and occasionally the patient, as I lately witnessed, perishes as if in 
the paroxysm of a malignant intermittent. This great liability to be 
affected by the causes which produce other forms of fever, gives much di- 
versity to the erysipelatous type, and forbids a reliance on any uniform 
method of treatment so successfully followed in the phlogistic or periodical 
fevers. 



638 THE PRINCIPAL DISEASES OF THE 

I feel incapable of prying deeper into the pathology of this disease, and 
shall proceed to speak of the treatment, chiefly according to the experience 
of our physicians during the late epidemic. 



SECTION V. 

EPIDEMIC ERYSIPELAS, CONTINUED : — TREATMENT. 

I. We can raise no valid objection to the opinion that erysipelas is a pe- 
culiar fever, from the fact that treatment frequently arrests it ; for autumnal 
fever, syphilis, and goitre are peculiar maladies, and yet they may be 
arrested. Still, though often cured, in many cases it proves fatal, and 
should always be regarded as a dangerous disease. It will be proper, first, 
to say something on the means of arresting it in the early or forming stage. 

II. When the constitution is good and fever has not yet become developed, 
the topical treatment is most likely to be successful. The erysipelatous 
diathesis of the organism is not yet fully established; the disease has more 
of a local character, and is of course more amenable to local treatment. 
When that treatment fails — when the inflammation passes over the circuin- 
vallation produced by the caustic, or, arrested at the point of first outbreak, 
appears in some distant part of the body, whether cutaneous, mucous, 
serous, cellular, or fibrous, it is because there is a constitutional lesion. 
The various functions may not yet have appeared in disorder, but the access 
of fever is near. In this stage of incubation, and subsequently up to the 
full development of a hot stage, vigorous efforts should be made by consti- 
tutional treatment, for there is a prospect of cutting short the disease. It 
will rarely happen that bloodletting is proper in this stage, yet cases may 
occur in which the state of the pulse will demand it. Of all the means 
within our reach, emetics or emetico-cathartics are undoubtedly the best. 
The vomiting should be free, and the purging of that kind — cholagogue — 
that will give bilious discharges. These evacuations should be followed 
by gentle sudorifics, such as Dover's powder, or a compound draught of 
paregoric, wine of ipecac, and spirit of nitrous ether, to be followed by some 
diaphoretic infusion. If these measures with the local treatment should 
not succeed, the fever will, of course, soon become established, and we must 
now review the means of cure adapted to the disease in its full development. 

III. As no fever presents more destructive inflammations than erysipelas, 
it might at first view be supposed that bloodletting would be a chief remedy; 
but experience has not borne out this supposition. The phlogistic diathesis 
is so modified in this fever, that in many cases the progress of the inflamma- 
tion is not arrested by venesection, and, in some, the vital powers are so 
enfeebled by the loss of blood as to show that the lancet should not have been 
employed. When the inflammation has attacked the fibrous structures of 
the joints and bones, simulating rheumatism, or the serous membranes of 



INTERIOR VALLEY OF NORTH AMERICA. 639 

the great cavities, presenting us with the phenomena of meningitis, pleuro- 
pneumonia, or peritonitis, the lancet was most efficient. When confined to 
the skin, mucous membranes, areolar tissue, or lymphatic ganglia, blood- 
letting afforded much less relief, and in many cases, in the North as well as 
in the South, either did harm, or was so manifestly contra-indicated, as not to 
be employed. The cellular and glandular suppurations and sloughings were 
not prevented by it; and the atony which followed on the loss of blood ren- 
dered those disorganizations still more dangerous to life. In cases requiring 
the lancet, a single operation was generally sufficient; yet two or three were 
occasionally found indispensable. Those bleedings in which the flow was 
copious in a short time, were found most effective; and if it happened 
that the loss of blood was improper, the injury done was much less than 
when the same quantity was abstracted slowly. In all cases, the earlier the 
bloodletting after the stage of reaction has arisen, the better was the result; 
when the work of effusion, suppuration and sloughing had become esta- 
blished, but little relief was experienced, even in cases which might have 
been arrested or greatly mitigated by an early resort to that remedy. The 
fever in this disease was very generally prone to slide into an adynamic or 
typhous character; or, in localities infested with periodical fevers, into that 
kind of collapse or sinking of the vital powers, which constitutes an essential 
element of the malignant paroxysm. It was these tendencies more than 
any other that contra-indicated bloodletting, and especially rendered its 
repetition improper after the first three or four days. I have said that 
venesection was not so necessary when the inflammation was seated in the 
mucous as the serous or sero-fibrous membranes, but from this remark we 
must except invasions of the lining membrane of the larynx, causing an 
cedematous laryngitis. The imminent danger of suffocation when the in- 
flammation had that seat, rendered copious and repeated venesection indis- 
pensable, although it might not at all times prove effectual. "While the 
disease was epidemic in Mississippi, Dr. Harper, of Port Gibson, after 
attending a medical friend who died of it, took a shower-bath at bedtime, 
and found himself in the morning with fever, hoarseness, and aphonia. The 
sense of constriction in the glottis was such as to suggest inevitable suffo- 
cation. Deglutition was difficult and considerable coma and delirium 
speedily supervened. He was bled three times in one day, and I saw him 
a few months afterwards in good health. 

I have endeavored to trace out the influence of climate and topographical 
aspect on the influence of bloodletting in this malady, and find that it was 
employed and repudiated by different physicians in the North and in the South. 
Thus in the latitudes of forty-three, four, and five degrees, a large number 
of practitioners omitted it entirely, and in the latitudes of thirty-two and 
thirty-three degrees, several, as Dr. Wharton, of Grand Gulf, found it bene- 
ficial. In low valley plains, infested with periodical fevers, bloodletting 
was less admissible than on the hilly lands; and yet this statement must be 



640 THE PRINCIPAL DISEASES OF THE 

received with some exceptions, for on the prairies of Illinois, which, although 
rolling, partake largely of the character of alluvial valleys and are infested 
with autumnal fevers, Dr. Henry, at Bloomington, bled most of his patients 
freely, and found it not only safe but beneficial. 

Observation has taught me that the estimates of our physicians on the 
subject of bloodletting in this and many other febrile diseases, are to some 
extent modified by their education. We every day see physicians (being 
also private teachers) living in the same localities, who entertain widely 
different opinions on the subject of bloodletting, and present in its employ- 
ment equal diversity; some resorting to it in almost every form and grade 
of acute disease, while others employ it hesitatingly even in the most vio- 
lent. A lineal professional descendant of Dr. Rush is ever ready to use the 
lancet, and generally sees it do some kind of good, while a traditional fol- 
lower of Brown, or of some physician who grappled with the spotted fever 
of New England from 1806 to 1812, as generally sees in venesection the 
cause of whatever evil may follow on its employment. Even the intellectual 
character of the physician will influence him in the employment of this 
potent therapeutic agent, more perhaps than any other. Thus, of two 
physicians educated alike and taught the same doctrines and practical pre- 
cepts, he who is of a bold and reckless temper is quite certain to bleed more 
frequently and copiously, under the same circumstances, than the man of a 
cautious and timid spirit ; and each will be, to some extent, incapable of 
estimating the consequences of doing too much or too little. 

IV. Emetics, at all times more or less employed in the treatment of 
sporadic erysipelas, were very generally used in this epidemic, and the testi- 
mony in their favor, is, on the whole, more decided than that in favor of 
venesection. They were regarded as applicable to a greater number of cases, 
and their operation was never followed by effects of a doubtful character. 
My own experience would lead me to confide in emetic medicines, especially 
tartarized antimony, in erysipelatous fever, more than I would confide in 
any other contra-stimulant or antiphlogistic medicine. These medicines, we 
know, have a specific influence on the tegumentary membrane. Thus they 
promote perspiration, they act also on the alimentary mucous membrane, as 
we see from the increased secretion in the mouth and pharynx under nausea, 
and from the liquid alvine discharges which follow the union of minute 
drops of tartar emetic with cathartic medicines; finally, above all other 
medicines, they re-establish and promote secretion from the mucous mem- 
brane of the respiratory passages. As contra-stimulants, they lower the tone 
of the sanguiferous system, with an energy unequalled by anything but the 
lancet, and, at the same time, from that specific influence on the capillary 
vessels which enables them to increase the secretion of the tegumentary 
system, they abate congestion wherever it may exist. These various effects 
may occur independently of vomiting, and in cases highly phlogistic it may 
be well to aim at their production with doses that merely nauseate j but 



INTERIOR VALLEY OF NORTH AMERICA. 641 

after free venesection in such cases, and in others where the arterial excite- 
ment does not run high, but the inflammation either spreads rapidly, or 
assumes that aspect which indicates a failure of the vital forces, full vomiting 
is greatly to be preferred to protracted nausea, and is almost invariably fol- 
lowed by an abatement of fever, congestion, and inflammation, with an 
improved condition of the vital susceptibilities. If vomiting be attempted 
when the tone of the heart and arteries is great, the operation will be im- 
perfect and unsatisfactory in its results. If it be postponed for several 
hours after bloodletting, it will be less beneficial. The proper time is the 
earliest practicable period after the bleeding. The first portion of the 
emetic may even be administered before the vein is opened. The beneficial 
influence of vomiting, and the exemption from all injurious effects, are 
greater immediately after the loss of blood than at any other time. Still 
further, if it should be that the bleeding was more or less improper, and 
the vital powers are about to fail in consequence, early and full vomiting 
will arrest the sinking and bring on reaction. In the economy of the living 
system, spontaneous vomiting is a preventive of syncope from loss of blood. 
The patient who vomits under venesection, seldom faints. 

When the phlogistic diathesis runs high, tartarized antimony is the 
best emetic. It may be administered alone, or in a solution of nitrate of 
potash, or in powders of the same medicine with calomel, or in an infusion 
of lobelia inflata. When the energy of the circulation is small, tartar 
emetic may be advantageously exchanged for ipecac, which may be ad- 
ministered alone, or in the lobelia infusion, or, as was done by Dr. Dawson, 
in a solution of common salt. When the throat is greatly affected, capsi- 
cum may be advantageously added to the salt and ipecac, for the sake of 
its action on the inflamed membrane. It may be advantageous to vomit 
the patient for two or three successive days ; but the greater part of those 
who treated the late epidemic administered but one emetic. The laryngeal 
and pulmonary complications are those which most require a repetition of 
emetic medicines. In advanced stages of the disease, when extensive sup- 
purations and sloughings have occurred, or a great capillary stasis is about 
to be followed by gangrene, a stimulating emetic of rapid operation will so 
improve the sensibility and irritability of the system as to give to the tonics, 
stimulants, and gentle narcotics, then indicated, an influence which they 
might not otherwise exert. One or two other evacuations should follow that 
produced by vomiting, and to them we must now give attention. 

Y. Cathartics. — Purging was still more constantly employed in this 
epidemic than vomiting. It is most efficacious when it immediately follows 
the vomiting, is thorough in emptying the cells of the colon, promotes a 
free secretion from the liver and mucous membrane, and is not allowed to 
continue very long. Under these regulations it removes all irritating sub- 
stances from the bowels, reduces the force of the heart, and relieves the 
inflammatory condition of the skin by introversion of blood. When the 

VOL. II. 41 



642 THE PRINCIPAL DISEASES OF THE 

integuments of the face and head, external or internal, are the seats of 
inflammation, purging is not only safer, but more beneficial than vomiting, 
as it diverts from those parts more effectively than any other therapeutic 
agency, and when the fibrous textures of the extremities are chiefly affected, 
presenting a quasi rheumatism, purging is equally proper; but when the 
respiratory apparatus is the chief seat of lesion its power is much less. 

The best cathartics are calomel and the purgative salts, to which an anti- 
monial may be advantageously added. Indeed, an emetico-cathartic, as a 
solution of Epsom salt and tartarized antimony, or the latter with nitre and 
calomel, as mentioned under the preceding head, or a powder of calomel 
jalap and tartar, are the very best cathartics in the common run of cases. 
When the powers of the system are greatly reduced, if it should still be 
thought advisable to act on the bowels, an infusion of senna and gentian, or 
castor oil with oil of turpentine, will be most proper. In cases where the 
peritoneum is chiefly involved, the best cathartic is calomel in five or ten 
grain doses, alternated with one or two drachm doses of castor oil. 

VI. Sudorifics. — An important part of the benefit produced by vomiting 
and by emetic medicines, is the tendency to diaphoresis which follows their 
administration. This tendency should always be promoted by a suitable 
regimen, and the appropriate adjuvants. To patients, who had not been 
previously costive, and have no abdominal distension, we may often, with 
advantage, administer sudorifics immediately after the operation of the 
emetic, postponing evacuation from the bowels till that from the skin has 
been promoted, or we have failed in the effort to accomplish this. As a 
general rule, some preparation of opium should invariably find a place in 
our diaphoretic formulas. The irritability following on rapid and copious 
depletion, and the burning pain of the inflamed parts, require in many 
cases a liberal opiate. Repose must be produced, or there will be no per- 
spiration. As to the other ingredients, it cannot be important which are 
chosen. By different physicians a great variety were employed, and all, 
perhaps, with equal advantage. Should the febrile excitement be moderated 
by the measures which have been pointed out, and a diaphoresis be esta- 
blished, the inflammation will commonly cease to spread, and very soon 
begin to fade away. The perspiration, however, may prove transient 01 
partial, the pulse may re-acquire its morbid energy, and the condition for 
which the first evacuants were prescribed may be reproduced. Under such 
circumstances, a second bleeding may be of signal service, the sudorifics 
being unabatingly continued; or if the physician doubt its safety, the nau- 
seating element of the diaphoretic doses may be so augmented as to occasion 
vomiting. In either case, a favorable perspiration, with sleep, is likely to 
follow. The antiphlogistic line of treatment, here pointed out, is one of 
decided power, but of brief duration of effect. Its energy and brevity of 
action are the sources of its success. The earlier it is employed the better. 
After the second or third day from the access of the fever, its efficacy will 



INTERIOR VALLEY OF NORTH AMERICA. 643 

be altogether doubtful, and at whatsoever time commenced, it cannot be 
continued loDger than two or three days. (Edematous infiltrations, suppu- 
rations, sloughing, or gangrene, with failure of the constitutional energies, 
are impending events, and, once begun, contraindicate further depletion. 

VII. Stimulants and Tonics.— As in sporadic erysipelas, so in the late 
epidemic, these medicines were sometimes demanded. Infancy, advanced 
age, a nervo-phlegmatic temperament, a constitution broken down by ex- 
cesses, or some actual chronic disease, especially when accompanied with a 
local lesion, were conditions which, in different patients, interfered with the 
full development of inflammatory fever and inflammation. The former par- 
took largely of an adynamic type, and the latter of passive hyperemia, 
tending to disorganization of the tissue, but not by active inflammatory 
action. In many instances, moreover, although the access of the hot stage 
seemed to threaten a fever of high excitement, adynamia followed on mode- 
rate depletion, and demanded an early change of treatment. It was always 
useful to connect the administration of stimulants and tonics with diapho- 
retics, to restore or maintain the functions of the skin, while the inner- 
vation and circulation were invigorated. The latter was, indeed, indispen- 
sable to the successful maintenance of the former, and, at the same time, a 
free secretion from the skin was one of the safest guarantees against injury 
from excessive or untimely stimulations. It is not necessary to go into 
details under this head. The stimulants commonly employed were spiritus 
Mindereri, carbonate of ammonia, camphor, opium, and wine or brandy; 
the tonics, bark in decoction, with one of the mineral acids, and the sul- 
phate of quinine. 

The more acute the inflammation in the beginning, the less was the neces- 
sity for those medicines in the more advauced or closing stages, except when 
extensive suppurations made their usual demand for corroborants and 
nutrients. There were, however, two or three modifications of the erysipe- 
latous diathesis, which especially demanded the remedies now under conside- 
ration. Whenever, as frequently happened, and much more in some localities 
than others, an early or decided development of typhous symptoms occurred, 
it was necessary to meet them with stimulants. But in this disease, as in 
the primary typhous fevers, the symptoms of disordered innervation were 
sometimes dependent on simple irritation and adynamia of the brain, at 
other times on an extension of the inflammation to the membranes of that 
organ; and the differential diagnosis was not always clear. In some cases 
of this kind, Dr. Hall gave tartar emetic and opium combined, with the 
happiest effects. 

Another modification of the erysipelatous type, was what may be called 
the malarial. In some southern localities, the phlogistic diathesis was but 
little developed, the fever displayed an obscure periodicity, with a tendency 
to what is there called collapse, under which circumstances the early and 



644 THE PRINCIPAL DISEASES OF THE 

liberal administration of the bark or the sulphate of quinine with opium or 
one of its preparations, was indispensable to the safety of the patient. 

A third condition Of the system demanding an early resort to excitants 
and corroborants, was the alcoholic cachexia giving a special tendency to 
gangrene of the inflamed parts, and from the outset rendering all active de- 
pletion, except by vomits, improper. 

In forming a judgment as to the use of .internal stimulants and tonics, 
the condition and aspect of the inflamed part afford important information. 
Acute pain, great tenderness under pressure, tension, and (for this kind of 
inflammation), a bright red, declare that internal stimulation is not de- 
manded. On the other hand, the comparative absence of these symptoms 
with oedema, and a dark or livid hue, admonish us to refrain from all re- 
ducing measures, and push those which may support the vital powers. 

Topical Applications. — 1. Local bleeding was often resorted to and 
seems to have been serviceable. Being in a great degree a country epidemic, 
leeches were not within the reach of those on whom the treatment chiefly 
rested. Nor were cups often applied to the inflamed surface. Simple scari- 
fication with the lancet, scalpel, or bistoury, according to the depth of the 
inflammation, was, however, very generally practised, and the incisions were 
found to bleed freely. In this manner the throat was often promptly re- 
lieved ; and some cases of cedematous laryngitis which proved fatal might 
perhaps have been arrested if the scarification had been carried to the rima 
glottidis instead of being limited to the palatal arches and intervening ton- 
sils. When the disease assumed the character of glossitis, and the tongue 
became swollen, suggesting the popular appellation of black tongue, deep 
longitudinal incisions afforded great relief. When the subcutaneous areolar 
tissue was filled with serum to distension, punctures drained it away to the 
comfort of the patient ; and when deeper-seated secretions of sero-fibrinous 
or purulent fluid began to form, incisions of corresponding depth, with 
warm fomentations to encourage the flow of blood, were found highly bene- 
ficial. 

2. Nitrate of Silver. — I have already spoken of this medicine as employed 
to arrest the formation of the disease. It remains to say that it was em- 
ployed by most of our physicians in every stage of the inflammation ; not 
only to prevent its extension, but to cure it in the surfaces where it had 
become established. The reports of its effects are various and contradictory. 
Applied to the sound skin, it sometimes prevented a further extension of 
the erythema ; but not so constantly as to inspire great confidence in its 
power. Applied in strong solution over the inflamed surface, it was said to 
subdue the inflammation, but we must recollect that it is the nature of this 
erythema to die away in the parts over which it has travelled, and therefore 
we may readily mistake a spontaneous abatement for one produced by our 
remedies. 

3. Corrosive Sublimate. — The publication of the experience of Dr. Trip- 



INTERIOR VALLEY OF NORTH AMERICA. 645 

ler, U. S. A., with a solution of the deuto-chloride of mercury, was made 
in 1842,* yet I do not discover that many of our physicians adopted the 
practice which he declared had been signally successful in his hands. In 
all his patients the face and head were the seats of the inflammation. It 
was not immediately arrested, but as nearly every one escaped an extension 
or translation of the disease to the brain, he came to the conclusion that the 
solution protected that organ. His formula was a scruple of the deuto- 
chloride to the ounce of distilled water/applied several times a day over the 
inflamed and the immediately surrounding healthy skin. The Doctor cites 
Dr. Pitcher, late U. S. A. surgeon, as authority for the practice, and says, 
that gentleman had found it eminently successful. Dr. Dawson, however, 
informs us that his trials with this medicine gave no satisfactory results. 

4. Tincture of Iodine. — No topical application to the inflamed skin was 
more frequently made than this. It was spread over both the inflamed and 
the adjacent sound surface. When the fever was intense it did no good, 
but rather increased the anguish of the affected part. In milder cases, how- 
ever, it frequently arrested the inflammation. To a difference in the state 
of the general system, we may perhaps ascribe the diversity of reports on 
this as well as some other topical applications. In the Louisville Hospital 
this was a standing application, and as the erysipelatous patients were 
assigned to the surgical ward, Prof. Gross had opportunities somewhat ex- 
tensive for observing the effects of this compared with some other applica- 
tions. The result was a decided preference for the iodine over every other. 

5. Blisters were of course employed by the majority. In some cases 
they arrested the spread of the inflammation, in others they failed. When 
the difficulty of swallowing was great, or the condition of the larynx threat- 
ened suffocation, applied to the nucha they often gave relief, and in affec- 
tions of the lungs, pleura, peritoneum, and dura mater, they were equally 
beneficial. 

I have enumerated the local applications most relied upon; but many others 
were employed with, perhaps, equal advantage. Of these I may name the 
following: solutions of sulphate of copper ; of muriate of ammonia; or* sul- 
phate of iron ; and of acetate of lead ; diluted tincture of camphor, spirit of 
turpentine, mucilage of elm-bark; a liniment of olive oil and wheaten flour; 
mercurial ointment, common lard. It is obvious, that applications so very 
different in therapeutic qualities, could not be equally well adapted to the 
same cases ; but we may admit that all were useful when used discrimi- 
natingly. But how can such discrimination be exercised ? I am compelled 
by experience and inquiry to believe that the criteria by which to select the 
topical applications in this acute, not less than many chronic affections of 
the skin, are as yet but little understood, and perhaps will never be very 
obvious. It has long seemed to me, that the practice with these agents was 
essentially empirical and tentative ; it will, I fear, continue so. That they 

* West. Jour. (Louisville), for December, 1842. 



646 THE PRINCIPAL DISEASES, ETC. 

have all done good cannot be doubted; yet, as they are always used in con- 
nection with constitutional treatment, it must be quite impossible to decide 
on the relative value of the external and the internal. That the latter is 
on the whole much greater than the former is, I think, quite certain ; and 
it seems exceedingly probable that in many cases the cure depends entirely 
upon the internal, while the external applications may receive the credit. 
In this way we may account in part, at least, for the opposite reports made 
by different physicians on the efficacy of the same application. One has 
used it in connection with an appropriate, the other an inappropriate inter- 
nal treatment, and consequently the apparent results were different. In the 
midst of this uncertainty we may perceive that when the constitution of the 
patient is vigorous, and the phlogistic diathesis is strongly developed, the 
mucilaginous, farinaceous, and oleaginous applications may be most proper, 
while in feeble constitutions, with an early failure of the vital forces, and a 
tendency to oedema or gangrene, the more stimulating should be chosen. 

The applications to the throat were almost as various as those to the skin. 
The principal were the infusion of rose petals acidulated with muriatic acid, 
a saline infusion of capsicum, the tincture of myrrh, a tincture of oil of 
turpentine, honey, and gum Arabic, tincture of iodine, solution of nitrate of 
silver; and to ulcers, the solid caustic. The remarks which have been 
made on the choice and effects of applications to the skin are appropriate to 
those for the throat and mouth, and need not be repeated. 



PART FIFTH. 
PHLOGISTIC FEVERS! THE PHLEGMASIA. 



CHAPTER I. 

COMPARISON WITH THE PREVIOUS GROUPS— CLASSIFICATION. 



SECTION I. 



COMPARISONS AND CONTRASTS. 



I. Every fever referred to in the four groups which have been studied, 
may be, and often is, complicated with inflammation; yet, as we have con- 
cluded, the former may exist without the latter. In the phlogistic or in- 
flammatory fevers, at which we have now arrived, inflammation is always 
present, and may, so to speak, exist and run its course without fever ; that 
is, according to its extent or intensity, it may or may not cause that morbid 
affection of the general system. This view assumes that the fevers now 
under consideration depend on inflammations as their (pathological) cause ; 
but this is not universally true, for we often see the signs of fever as early 
as those of inflammation, and sometimes earlier, in which case they are the 
twin brothers of a common parent with the order of their delivery reversed. 
And here we perceive a connecting link between the phlogistic and other 
groups of fever, all of which in their progress are liable to develop or become 
combined with inflammation. As a general and provisional expression they 
may be said to cause inflammation, while the phlegmasiae are caused by in- 
flammation. But whether the inflammation breed the fever or is generated 
thereby, it becomes the chief cause of danger in every febrile disease, and 
presents us with another element of identity — another pathological trait 
common to the whole. 

II. As might be expected from what has just been said, wh.i\epost mortem 
inspections often fail to reveal the signs and effects of inflammation in per- 
sons who have died from the fevers of the groups we have been studying, 
such ravages are never absent after death from the fevers we are now to 



648 THE PRINCIPAL DISEASES OP THE 

study. Still further, the anatomical characteristics of the secondary in- 
flammation, or that produced by the fever, are not exactly the same as those 
of the primary inflammation, or that which produces the fever. A copious 
effusion of strongly coagulating and plastic lymph, an early suppuration, or 
a tendency to gangrene, characterize this inflammation, and present derange- 
ments of structure which are unmistakable ; but in the secondary inflamma- 
tions, although the sanguineous congestion may have been great, the effusions 
are more serous than fibrinous, the adhesions and consolidations of structure 
less, and both suppuration and gangrene of rarer occurrence. 

III. In harmony with these traits of morbid anatomy, are the symptoms 
which have at all times been taken as signs of inflammation and (inflamma- 
tory fever) a phlogistic diathesis, the most constant and characteristic of which 
are exalted sensibility and great activity of calorific function in the part 
affected, a hard or resisting pulse, and a state of hyperinosis or increase in 
the fibrinous element of the blood. The inflammatory orgasm indicated by 
these symptoms is commonly greatest in the early stages of the fever. 
Diminishing by time or under the influence of treatment, both the inflamma- 
tion and the fever may become subacute or chronic. The fever may at length 
cease, leaving the inflammation which had caused it to run a more protracted 
course. If the local affection, however, should be subdued, the fever will 
cease, unless a secondary inflammation should have been established. When 
this happens, and the primary inflammation is cured, the case becomes in a 
manner identical with those fevers which do not arise from but generate in- 
flammations, all of which are prolonged or aggravated by the reactive influ- 
ence of the local affections which they themselves have generated. Yet 
there is this difference between the phlogistic and the other fevers, in the 
aspect we are now viewing them, that when the secondary inflammation in the 
former is subdued the fever ceases, but it may be subdued in the latter and 
the fever still continue. 

IY. The febrile diathesis of all the phlegmasise or phlogistic fevers is 
substantially the same. y Passing by the seat of the inflammation, these 
fevers have as true and well-marked specific characters as the various modi- 
fications of autumnal or periodical, or the different forms of typhous fever; 
and referring to the constitutional affection only, we might speak of one dis- 
ease, an inflammatory fever. Yet even thus viewed there is room for 
varieties of type, which result chiefly from what has led to distinct noso- 
logical designations, everywhere received, viz. : the seat of the primary 
inflammation. Thus, when the inflammation is seated in a serous membrane, 
the febrile type is not the same as when seated in a mucous membrane, yet 
it is in both cases phlogistic. The diversity of symptoms, however, which 
the phlegmasiae exhibit, is not so much found in the character of the fever 
as in the functions of the organ in which the inflammation is seated j and 
the new symptoms which may spring up in the progress of the fever do not 
so much depend on any change in the constitutional diathesis, as on the 



INTERIOR VALLEY OP NORTH AMERICA. 649 

supervention of a secondary inflammation in some other organ. This modi- 
fication of the symptoms from supervening inflammation is not confined to 
the group now under consideration, but is more or less true of all the groups 
through which we have passed. Thus, when in different cases of autumnal 
remittent, the brain, the stomach, or the liver, becomes the seat of inflamma- 
tion, the character of the disease undergoes a decided change ; and in con- 
tinued fever the localization may be in the brain, the lungs, the stomach, or 
the ileum, whereby, or whereupon, the symptoms are so modified as to suggest 
to one nosologist distinct species, while another regards them but as the 
necessary results of the different seats of the secondary congestions or in- 
flammations. Yellow fever and the eruptive fevers present us with similar 
facts, and appear to suggest the existence of a law of modification common 
to all febrile affections. 

V. In our diagnosis of the phlogistic fevers, our attention is most point- 
edly turned to the symptoms immediately connected with the affected organ ; 
in diagnosing the other febrile diseases we look more to the disturbances of 
the organism at large. The inflammation fixes our attention in one case — 
the fever in the other. Thus we pass lightly over the constitutional symp- 
toms, but labor patiently to decide whether the inflammation is seated in the 
stomach or the peritoneum, in the mucous, cellular, or serous tissue of the 
lungs. But in our periodical and continued fevers we find little room in 
the beginning for such inquiries, and pronounce one bilious remittent, 
another typhous, while as yet we have discovered no primary local affec- 
tion. The same thing is true of yellow fever and natural small-pox. It 
would be illogical to affirm that these different modes of diagnosis prove, 
that while the phlogistic fevers have an inflammatory origin, the others 
have not : yet it must be admitted that if such were the fact, the present 
differences in our methods of diagnosis would be those we should still 
employ. 

VI. The phlogistic fevers are essentially and decidedly continued, and in 
that respect stand in strong contrast with autumnal fever. Yet an acute 
secondary inflammation, established early in the latter, may transform it into 
a phlogistic fever with slight remissions, such as a true phlegmasia exhibits 
when it begins to decline. These two forms of fever can and indeed do 
signally modify each other, as we shall hereafter see. Widely as they differ 
in many points they concur in others. Thus, left to themselves they run 
on indefinitely, yet both may at last terminate in health independently of 
treatment. Both, moreover, may be arrested by remedies, though of a diffe- 
rent kind. Compared with yellow fever the phlegmasia differ in being 
curable and not self-limited, while that fever is self-limited, and in general 
not curable. The continued or typhous fevers may, like the periodical, be 
changed into quasi phlegmasia, and in turn may greatly modify the type 
of the latter. The two forms differ essentially in their relation to thera- 
peutic agencies, the phlogistic yielding to them, while the typhous with in- 



650 THE PRINCIPAL DISEASES OF THE 

definite self-limitation holds on its course, to terminate, in health perhaps, 
after all medication has been given up. It is well known, that when a phlo- 
gistic diathesis is epidemic, it gives to the eruptive fevers a more inflamma- 
tory type, and favors the development of secondary inflammation. The two 
groups are identical in unabated continuity ; but they differ signally in this, 
that while the phlegmasia, if not cut short by therapeutic measures, continue 
indefinitely, each of the true eruptive fevers, resisting such measures, is 
strikingly self-limited. 

VII. It is in their etiology that we find the greatest contrast between the 
phlogistic and the other forms of fever. Most of the latter result from 
specific agents, of a deleterious character. Of this kind are the morbid 
poisons which cause the eruptive fevers, the malaria which generates period- 
ical fever, that which originates yellow, and those which seem to produce 
the typhous fevers. Should it appear, hereafter, that any or all of these 
maladies are not the result of peculiar poisons, they would still be referred 
to respectively a peculiar combination of agents or influences, with which 
the causes of the phlogistic fevers would stand as much in contrast, as they 
stand with specific poisons. An enumeration of the principal causes of the 
phlegmasia^ especially those of our own country, will be made hereafter. It 
will be sufficient for our present purpose, to say, that they are not agents 
which possess inherent morbific properties, but largely the opposite ; that is, 
they are sustainers of life ) and become causes of inflammation and fever, 
by being applied in excess, or (indirectly) by being withheld, by improper 
combination, or by untimely or misplaced application. Thus they are the 
things in the midst of which, and by which, to employ the beautiful lan- 
guage of holy writ, we " live, and move, and have our being." It is easy 
to perceive, and admit, that an inflammation and fever raised by such agency 
must differ widely and favorably from the effects of any agent, that is from 
the causes which, malum per se, produce the fevers of the other groups. 
In the phlogistic fevers the inflammation may be violent, the fever acute, 
the phlogistic diathesis intense, but to speak in metaphor, the lateral depar- 
ture from the right line of health, the deterioration and degradation of both 
solids and fluids must be incomparably less, than that resulting from agents 
which, in any quantity, disturb or pervert instead of increasing the healthy 
activity of the functions. And this a priori view, is fully borne out, by 
what we know of the condition of the blood in the phlegmasia, which con- 
sists, as we have seen, in augmented and not deteriorated development of 
the most important element, fibrine, which being effused blends itself with 
the tissues, adheres to them by a vital affinity, and does injury only by its 
mechanical properties ; while it performs a function in the reproduction of 
injured or lost parts, which is indispensable, and which, from its deficiency or 
deterioration, in many other forms of fever, it executes imperfectly or not at all. 

These general views may serve as an introduction to the study of the 
phlegmasias. It is not advisable, however, to enter at once on particular 



INTERIOR VALLEY OF NORTH AMERICA. 651 

forms, as they have many common characteristics, and may, to a certain 
point, be studied in the concrete. 



SECTION II. 

CLASSIFICATION. 

Whatever may be the difficulty in classing most of the fevers we have 
studied by a primary anatomical seat, those of the present group present 
none, — cannot, indeed, be classed in any other way. They who have been 
most intent on bringing all fevers under the law by which the phlegmasise 
are classified, have attached an importance to the inquiry, which has not, I 
think, been shown. If it should, finally, be demonstrated that they respec- 
tively spring from the primary inflammation, the seats of which would, of 
course, be known, the discovery would not make them phlegmasia — would 
not fuse the whole into one natural group ; for the same differences of in- 
flammatory and febrile type, which are now recognized, would still exist; 
the power which etiology exercises over febrile pathology would remain, and 
make itself respected by the practical physician. 

If we look at the phlegmasia by the light of the fever, we see, as it were, 
but one, while viewed through their causes, we have numberless ill-defined 
species, and we are, therefore, led to the seat of the inflammation, and 
instructed to rest our classification on an anatomical basis. In doing this, 
however, we meet with some difficulties. If guided by general anatomy, 
we derive a specific character from the tissue affected, and speak of serous, 
mucous, or fibrous inflammation, we should join together arachnitis and 
peritonitis, or unite pharyngitis, colitis, and bronchitis, either of which 
would be absurd. We must, therefore, derive a specific character from an 
organ, and construct varieties on the basis of the tissues which compose it; 
but in doing this, we may, with as much propriety, speak of genera and 
species, as of species and varieties. This method is that generally adopted, 
and upon it I have constructed the following systematic and comprehensive 
catalogue. 

This method, however, is not applicable to those phlegmasise which depend 
on special causes, and in the present state of our knowledge, must receive an 
etiological, instead of an anatomical classification. In what has yet been 
said they have not been taken into account, as their introduction would 
have interfered with that harmonious coalescence which it is my aim to 
show is a reality, as long as we include only the effects of ordinary causes. 
In the tabular view, those which depend on extraordinary or special causes 
are there presented in a supplementary form. 



652 THE PRINCIPAL DISEASES OP THE 

A. SIMPLE AND COMMON INFLAMMATIONS. 

I. Of the Cephalic and Spinal Organs : 

Cerebritis, Arachnitis tuberculosa, 

Piamatritis, Duramatritis, 

Arachnitis simplex, Myelitis. 

II. Inflammations of the Organs of Special Sensation : 

Retinitis, Conjunctivitis, 

Iritis, Otitis. 

III. Inflammation of the Organs of Locomotion : 



Myitis, Neuritis, 


Rheumatismus, 


Periostitis, Arthritis, 


Podagra. 


IV. Of the Organs of Respiration: 




Catarrh, Influenza, 


Pneumonitis, 


Laryngitis, 


Pleuritis, 


Tracheitis, 


Diaphragmitis, 


Bronchitis, 


Pneumonitis tuberculosa ? 


V. Of the Organs of Circulation : 




Pericarditis, 


Arteritis, 


Carditis, 


Phlebitis. 


Endocarditis, 




VI. Of the Digestive Organs : 




Glossitis, 


Colitis. 


Stomatitis, 


Architis, 


Tonsillitis, Parotitis, 


Hepatitis, 


Pharyngitis, 


Splenitis, 


Gastritis, 


Peritonitis. 


Ileitis, 




VII. Of the Urinary and Reproductive Organs : 


Nephritis, 


Orchitis, 


Cystitis, 


Metritis, 


Urethritis, 


Peritonitis puerperalis. 


VIII. Of the Cellular Tissue and Skin : 




Phlegmon, 


Mechanical injuries. 


Burns and Scalds, 




B. PECULIAR OR SPECIFIC 


INFLAMMATIONS. 


1. From Mineral Poisons. 




2. From Vegetable Poisons. 





3. From Animal Poisons. 

a. From Normal Secretions. 

b. From Abnormal Secretions, viz. : 

Malignant Pustule, Syphilis. 

Glanders, Gonorrhoea. 

c. From Decomposing Animal Substances ; Dissection Wound. 

A glance at this catalogue is sufficient to show that it includes a great 
number of the most formidable diseases we are called to encounter; some of 
which present serious difficulties in diagnosis, and a greater number demand 



INTERIOR VALLEY OF NORTH AMERICA. 653 

much skill and energy exerted at an early period for their subdual. It 
would be for a systematic treatise on pathology and practice to include the 
■whole ; but the plan of this work makes no such requirement, and even 
forbids it, for many of them are scarcely met with among us, and others 
have no claim to be admitted among the principal diseases of the Interior 
Valley. Regarding the whole, however, as partaking largely of a common 
constitution and local diathesis, it will be profitable, while studying a part, 
to have a list of the whole before us. What proportion will receive a 
further notice, I cannot now decide, but intend to omit all of which I have 
not seen enough to be qualified to appreciate what has been said of them by 
others ; and by observing this rule, those which but seldom occur among us 
will of course be excluded. We shall now proceed to the study of the 
etiology, pathology, and practice, common to the whole class, and then by 
analysis take up its subordinate divisions. 



CHAPTER II. 

/ 

ETIOLOGY OF THE PHLOGISTIC FEVERS— PREDISPOSING AND 
MODIFYING CAUSES— INTRODUCTION. 

The object of this chapter, is not to anticipate what must necessarily be 
said of the production of particular phlegmasice, but to consider in a gene- 
ral way the production of inflammation, per se, and of an inflammatory dia- 
thesis, by the agencies and influences which act upon the people of the In- 
terior Valley. Thus, it will embrace both hygiene and prophylaxis, while 
it will leave but little to be said on the etiology of those inflammations 
which may be specifically studied. 



SECTION I. 

TEMPERAMENT, INDIVIDUAL AND NATIONAL — AGE — SEX. 



I. Temperament. — As temperaments are transmissible, and our Inte- 
rior Valley presents an unceasing intermarriage of families and nations,* 
a well-marked specimen of those which the physiologists have made out is 
not very often seen. 

In the absence of statistics on a subject which scarcely admits of their being 
collected, I may professionally express the opinion, that the lymphatic and 
nervous temperaments give the least predisposition to the phlegmasia, and 
may sometimes even prevent them under the action of causes which, in a 
different temperament, might produce them. In those temperaments local 

* See Book i. Part iii. Chap. i. Vol. i. p. 637. 



654 THE PRINCIPAL DISEASES OF THE 

and constitutional irritation often take the place of inflammation and fever. 
Yet when these pathological conditions do arise, although they may not 
seem as intense as in subjects of a different temperament, they are danger- 
ous, because the vital forces are soon exhausted by the combined influence 
of an inflamed organ, and the depletions required or supposed to be required 
for its relief. The temperaments which most predispose to the phlogistic 
fevers, are the sanguine and the bilious. To which the greater influence 
should be assigned I am not prepared to say. The sanguine is sometimes 
weakened in its predisposing power by an infusion of the lymphatic ; and 
the bilious is quite as often reduced by the nervous. At other times we find 
them united in the same person, giving us a bilio-sanguineous temperament, 
which most of all favors both frequency of occurrence, and intensity of 
character in the phlegmasia. Left to themselves, patients of this tempera- 
ment are more apt to die than those which have the lymphatic or the ner- 
vous ; yet they bear a decided antiphlogistic treatment much better, and 
often present the noblest triumphs of the profession. 

Of the three varieties of the human race found in our Valley, the tem- 
perament of the Caucasian most favors the production of phlogistic fevers. 
Those of the African and Indian do not, however, preclude such fevers, but 
limit their number and diminish their intensity ; this is not the place to 
discuss the peculiarities of these races. Of our Caucasian population, the 
natives, sprung from English, Irish, Scotch, and German progenitors, are I 
think most obnoxious to the fevers we are considering, and next to them 
are, the emigrants from those countries. The national temperament of the 
whole is the sanguine, tempered by the bilious, phlegmatic, or nervous. 

Of the Hispano-Mexican population, resident within the southern basin, 
I cannot speak with confidence. Such as I have seen appeared to have the 
bilious temperament ; but I am not aware that they are prone to the phlegma- 
sia, against which their simple habits and vegetable diet may perhaps be a 
protection. 

The predominant temperament of the French Creoles of Louisiana, and 
the Habitans of Canada, living on the St. Lawrence and its tributaries, is 
the bilious. My inquiries lead me to the conclusion, that the former are 
less liable to the phlogistic fevers than the descendants of other European 
parents in the same region; but something must be allowed for their more 
temperate and listless modes of living. They are certainly less subject to 
these fevers than their brethren in the North, who eat large quantities of 
animal food, and experience the rigors of a higher latitude ; but whether 
these latter are as much predisposed to the phlogistic fevers, as their neigh- 
bors of English, Scotch, and Irish parentage, the facts I have collected do 
not enable me to decide. 

II. Age. — It is generally, and I think, correctly admitted, that infancy 
and childhood are periods of great comparative mortality in most parts of 
our Valley. How large a proportion of the deaths are caused by the phlegma- 



INTERIOR VALLEY OF NORTH AMERICA. 655 

si?e is unknown. It is quite certain that many young children die of con- 
vulsions, occasioned by irritations which would develop inflammation if 
death did not take place so soon. Many die of cholera infantum, diarrhoea, 
and dysentery, which may or may not be attended with mucous inflamma- 
tion. Many die of measles, and a much larger number of scarlatina. But 
in comparison with these and other less fruitful sources of mortality, we 
may I think place the phlegmasia, and pronounce them more than equal to 
all other causes of mortality. Those of the respiratory organs, especially 
the mucous membranes, are most frequent ; next come the inflammations of 
the brain, simple and tubercular, and lastly of the mucous membrane of the 
stomach and bowels, and the ganglia of the mesentery. The skin, the eye 
and the ear, are likewise the frequent seats of inflammation ; and it may be 
especially noted that those of the latter organ, occur oftener in the first few 
years, than in the whole of after-life. It appears from these facts that the 
great development of the arterial system, the highly arterialized state of the 
blood, and the lively sensibility and contractility of infancy and childhood, 
strongly predispose to the phlogistic fevers. At a more advanced stage of 
the ante-pubertal period, some of those phlegmasia become less frequent-, 
but those of the fibrous tissues, under the names of articular rheumatism 
and carditis, take their place. After puberty the predisposition is less, but 
continues throughout the period of active life with but little reduction ; yet 
the inflammations to some extent change their seat from the head and chest 
to the abdomen and pelvis. In the old age of the male, they oftener fix on the 
urinary organs than at an earlier period. At this advanced time of life, 
when the venous circulation predominates as it were over the arterial, and 
the vital properties of the solids have lost a portion of their activity, there 
is on the whole a diminished predisposition to the phlegmasia, but when 
they do occur, they are more fatal, though less intense. 

III. Sex. — From infancy to puberty, our male and female children have 
appeared to me equally subject to the phlegmasia. After the physiological 
epoch, which develops the peculiarities of sex, the male becomes more pre- 
disposed than the female, a result, perhaps of the predominance of the san- 
guineo-bilious temperament in one, of the nervo-lymphatic in the other sex. 
But much of the comparative liability of the sexes is indirect or incidental. 
Thus the function of child-bearing in women, leads to the more frequent 
development of inflammation in the pelvic and lower abdominal organs, 
while the out-door labors and exposures, from which, to the honor of man in 
this country, woman is so shielded, excite in him many inflammations, from 
which she remains comparatively exempt, though it must be confessed, that 
no small portion of her exemption is referrible to an avoidance of those in- 
temperate indulgences, which man mixes up with his exposures. From the 
difference in physiology, moreover, many causes which produce inflammation 
in men, excite only nervous irritations in women. As might be expected, 
this difference is a modifying influence, which must be taken into account 



656 THE PRINCIPAL DISEASES OF THE 

in the treatment of the phlegmasia of the two sexes ; the copious deple- 
tions, decisive contra-stimulations, and unrelenting efforts at translation or 
metastasis of morbid action, to which male patients are so often subjected, 
being generally inadmissible in the treatment of the other sex. 



SECTION II. 

CLIMATE. 

I. The southern or Mexican hydrographical basin* extends many de- 
grees into the torrid zone, and thus gives us a tropical climate. f Yet the 
close approximation of the high mountains or Cordilleras, to the Gulf of 
Mexico, subjects the inhabitants of the narrow tierras calientes, and the 
seamen of the Gulf, to depressions of temperature, which do not properly 
belong to a tropical climate. My personal observations have not extended 
into the torrid zone, but from what I have been able to learn in other modes, 
a high and sustained temperature does not produce or even predispose to 
the phlegmasiae generally. Of the whole, hepatitis occurs most frequently ; 
is perhaps the most legitimate offspring of regular long-continued heat. 
Pneumonia and rheumatism are, however, not unfrequent, but they may be 
regarded as the offspring of the northers, J which at certain seasons sweep 
over the Gulf and inhabited coasts, rather than the elevated mean tempera- 
ture. The seamen of the Gulf, and the people who reside on its shores, 
live in an atmosphere almost saturated with vapor, as the complement of 
the dew-point is always exceedingly limited, while the mean temperature of 
the year is high ; but from the small number of phlegmasiae we may infer 
that this quality of the air does not itself contribute to their production. 

II. Let us now pass from the torrid to the frigid zone, from a steady high 
to an equally steady low temperature, such as we find in the Arctic hydro- 
graphical basin. § We have here within the polar circle a mean tempera- 
ture of but two degrees, or seventy-eight below that within the tropics, || with 
a corresponding reduction of the proportion of atmospheric vapor. ^f Now, 
on the authority of the eminent travellers and navigators** who visited and 
sojourned in those frigid and dreary regions, it may be stated, that the 
Esquimaux, their indigenous inhabitants, are a robust and healthy race ; 
but what is more reliable and pertinent to our present inquiry, that the 
European and American seamen who spent from one to four years, exposed 
to the rigors of that climate, were less affected with the phlegmasice than in 
their native countries. Thus it appears that great reduction of temperature, 
if steadily maintained, in other words, that extreme and steady cold favors 
the production of inflammation and phlogistic fever even less than high and 

* See vol. i. pp. 29, 42, and 46. t Ibid. p. 455. \ Ibid. pp. 582, 609. 

I Ibid. p. 442. || Ibid. p. 459. \ Ibid. pp. 602, 606. ** Ibid. p. 437. 



INTERIOR VALLEY OF NORTH AMERICA. 657 

uniform heat. "We must now turn to the climates which connect these ex- 
tremes. 

III. The mean heat of our Interior Valley is about fifty degrees,* and the 
isothermal curve of that temperature lies near the southern side of the great 
lakes, between the forty-first and forty-second degrees of latitude. From 
the south, as we rise towards this line, the mean temperature decreases, 
but the variations increase ; from the north as we descend to it, the mean 
heat increases, and the variations likewise. In a certain sense we may say 
then that the curve of mean annual temperature is that of maximum varia- 
tion ; as the extremes of mean temperature present us with the minima of 
variation. - Finally, as these variations of heat bring with them variations 
of moisture and barometric pressure, we perceive at once the difference be- 
tween the climates of our temperate zone, and those which limit it to the 
south and north. 

Now what is the relation between these variable climates and our phleg- 
masia ? The answer is that of cause and effect ; for observation teaches 
us that the latter multiply in number, diversity, acuteness, and mortality, 
with thj3 increase of the former, whether we examine them in different lati- 
tudes or study their prevalence in connection with the steady temperatures 
of midsummer and midwinter, compared with the variable weather of the 
other periods of the year. Both the high heat of summer and the low heat 
of winter seem, however, to predispose the system to those inflammations, or 
at least increase the noxious influence of the sudden depressions of autumn 
and the equally sudden elevations of early spring, when on the whole the 
phlegmasise dependent on climate are most prevalent. 

Having recognized a cause of the phlegmasiae, let us inquire into its 
modus operandi. The enfeebling influence of extreme cold and extreme 
heat may be taken as an established fact. Another, equally admitted and 
pertinent to our inquiry, is that additions or subtractions of heat produce 
on organized bodies effects so much the greater as they have been imme- 
diately before exposed to the opposite temperature. The painful sensation 
in the hand which is plunged in to snow after having been held in hot water, 
the destructive influence of a high temperature on one who has been frozen, 
the rapid progress of returning vegetation after a hard winter, are evidences 
of a law which the experience of the world has recognized. We have then 
in variation of atmospheric temperature a stimulant of great and universal 
power, to which in the temperate zone we are perpetually exposed. Its 
action in the production of the phlegmasise is both predisposing and exciting ; 
thus constituting it a productive cause. As a predisposing agent it exalts 
the vital properties, augments tonicity, quickens the capillary circulation,, 
augments the activity of the functions, and thus creates what for want of a 
better mode of expression, I shall venture to call a physiological inflamma- 
tory diathesis, or a phlogistic temperament, such as characterizes the inha- 

* Ibid. p. 530. 

vol. ii. 42 



658 THE PRINCIPAL DISEASES OP THE 

bitants of the temperate zones, as compared with those of the torrid and the 
frigid. This, to speak figuratively, is the soil in which implanted exciting 
causes bring forth the phlegmasia. These causes are various, but one of 
them is the same variation of temperature which generated the predisposi- 
tion. Hence a sudden change of weather will excite in a person having this 
predisposition an acute inflammation, while, in others not having it the result 
will be a relapse of intermittent fever, a paroxysm of dyspepsia, or a fit of 
flatulent colic. The manner in which all this is brought about may not be 
very obvious ; but in general the equilibrium of the circulation is disturbed, 
and the viscera become engorged ; when, if the vital powers should be 
energetic and active, inflammation will be set up, if not, there will be only 
the disturbances of innervation and secretion which characterize the other 
forms of disease. 

Sudden variations of heat and moisture may, however, produce the phleg- 
masia in those who have no predisposition to them, but are, so to speak, in 
the opposite condition. Such is their effect on the long secluded, on the badly 
fed, on the ailing or infirm, whose conditions may in fact be regarded as 
predispositions to the phlegmasia, which in such systems are more intrac- 
table and fatal than in sound and vigorous constitutions. 

The conclusions at which we have arrived show us a striking connection 
between the sustainers and destroyers of life by inflammation. It is in the 
temperate zone that man reaches his highest physical, intellectual, moral, 
and social development, and in the same zone his inflammations are most 
multiplied and fatal. Neither effect depends merely on the direct influence 
of the climate, yet much of both should be referred to that head; while as 
much more might perhaps be traced up to climatic influences indirectly 
exerted. 



SECTION III. 



I. Diet. — It may be assumed that when the body is adequately, properly 
nourished with wholesome animal and vegetable food, it has its best pro- 
tection against the phlegmasia of the variable climates. If the inhabitants 
of the torrid zone, who live chiefly on vegetable diet, suffer but little from 
those fevers, we need not ascribe their exemption to their diet, because the 
climatic influences are absent. Yet, for them, a vegetable diet is doubtless 
the best, and should the animal food, appropriate to the colder climates, be 
adopted by them, it is probable that the number of their phlegmasia would 
increase. In like manner, the fatty animal food of the Esquimaux of our 
distant North is, no doubt, the best for them, as contributing more than 
any other to fortify them against the rigors of their climate ; yet, as the 
influences of atmospheric variation are little felt by them ; we cannot know 



INTERIOR VALLEY OF NORTH AMERICA. 659 

how much of their exemption arises from a diet which contains but a small 
proportion of the protein elements of the body. 

If, in the temperate climates, a supply of diversified aliment, suffcient to 
meet the physiological demands of the system, constitutes, as far as diet is 
concerned, the best protection against the phlegmasia?, it seems to follow 
that any great departure either towards deficiency or excess may favor the 
production of those maladies. Let us first consider the former. 

It is certainly not true that a habitual reduction below what may be 
called the normal standard, is necessarily productive of a predisposition to 
the phlegmasia?.; for it is well known that the trappers and voyageurs on 
the distant plains, rivers, and lakes, in the northwestern portions of the 
Valley, who eat much less than when at home, enjoy a great immunity 
from inflammations, though signally exposed to inclement weather. A 
gentleman,* who had been engaged in the fur trade, informed me that he 
once spent a winter at Sandy Lake, west of Lake Superior, during which 
the voyageurs, who were idle, ate heartily of wild meats, and became the 
subjects of pulmonary inflammation to an uncommon degree, showing that 
their ordinary food had previously contributed to counteract the effects of 
climate. Finally, it is well known that journeys to Santa Fe and the 
Rocky Mountains, attended, as they of necessity are, with reduction of diet, 
often cure subacute inflammations; as a similar reduction, honestly made 
by our patients, is known to do in the practice of medicine. It does not 
follow, however, that what is curative would have been preventive ; never- 
theless, we are instructed by these facts to believe that a reduction of diet, 
which gives a predisposition to the phlegmasias, must be one which impairs 
the energies of the system, and affects the natural density of the tissues, 
and renders them irritable. In such a quasi pathological condition, ex- 
citing causes readily awaken inflammations, often chronic, but sometimes 
acute, which are dangerous, and difficult to cure in proportion to the pre- 
vious degradation of the system. In looking beyond this degree of 
abstinence, we find that actual famine may become a producing cause of 
inflammation, and both gastritis and cerebritis have been found to arise 
before death from starvation. That these reactions of concentration do 
not occur in every case of total abstinence, we may well believe, from 
knowing that some systems sink under enfeebling influences, against which 
others rally, though the revived excitement may be neither healthy nor 
enduring. Such organisms may be said to die fighting. 

By a reference to the article Diet,*)" it will be seen that deficient food, 
except in individual cases, is not a predisposing cause of the phlegmasia? of 
our Valley, where, on the whole, the tendency is to excess, and to that 
subject we must now direct our attention. 

A full, stimulating, and nutritious diet, is the most powerful and perma- 
nent stimulus which our systems enjoy. It affects pleasantly the whole 

* Mr. W. Johnson, of Mackinac. t Vol. i. p. 653. 



660 THE PRINCIPAL DISEASES OF THE 

innervation, augments the volume, especially the protein elements, of the 
blood, and affords frequent and profuse supplies of nutriment to the tissues. 
Exerting its first and most exciting influence on the stomach, it constitutes 
that and the other abdominal organs a centre of copious fluxion, and the 
blood thus brought thither still further exalts the vital properties of that 
portion of the organism whence the augmented excitement is radiated 
throughout the whole. Thus, the heart is quickened in the force and fre- 
quency of its contractions, and the brain is either roused into unwonted 
activity of function, or oppressed by plethora and irregularity of circulation, 
inducing heaviness or sleep. 

It is undeniable that such a condition predisposes to the phlegmasia, 
though, it may be, not to them only. That pathological state may even 
supervene without the agency of an exciting cause, but'more certainly under 
its influence, although it might be of such feeble disturbing power, that in 
a lower grade of constitutional excitement, its action would be harmless. 
When inflammation is thus gotten up, its seat is sometimes settled by the 
previous infirmity of an organ, sometimes by the part having been most 
stimulated and oftenest brought into a state of physiological hyperemia, at 
other times, and, perhaps, most frequently, by the specific direction in the 
organism, which the exciting cause may take. In our Interior Valley, the 
fibrous and ligamentous tissues often suffer with rheumatism; and the brain, 
or its membranes, are frequently assailed ; but the organs most often and 
fatally involved, are the abdominal, which are thus compelled to make retri- 
bution for violations of their physiological laws by suffering from acute 
dyspepsia, or actual gastritis ; from duodenitis with the soubriquet of bilious 
colic j from ileitis, peritonitis, and hepatitis, all of which may arise even in- 
dependently of any exciting cause, except, perhaps, that of an occasional 
excess in eating ; or may follow on the application of an agent, which, with- 
out this predisposition, would be harmless. 

II. Drinks. — Tea and coffee so universally drunk by our people,* neither 
excite inflammation nor contribute directly to the production of a phlogistic 
diathesis. They disorder the innervation, however, and often establish in 
the stomach a morbid sensibility, and thus indirectly favor the production 
of subacute gastritis, rendering the differential diagnosis of the chronic 
affections of that organ somewhat difficult. 

Alcoholic drinks are undoubtedly more productive of inflammation. Of 
wines, much of the Sherry and Madeira drunk in the Valley is factitious 
and highly alcoholized, yet their consumption on the whole is not so great as 
to entitle them to much attention under this head.f The claret of the South 
containing much acid and but little alcohol j and the pure and weak wine 
made from our own vineyards,:): and known under the name of Catawba, 
cannot be classed with the causes of the phlegmasia. Most of our ales, 
porters, beers, and ciders, contain but little alcohol; yet as they include a 

* See vol. i. p. 658. t Ibid. p. 668. J Ibid. p. 669. 



INTERIOR VALLEY OF NORTH AMERICA. 661 

considerable amount of nutritive matter, and are often drunk in large quan- 
tities, they co-operate with a full diet in generating a phlogistic diathesis. 
Of ardent spirits a liberal quantity is consumed under the names of brandy 
and whiskey ; and what shall be said of them ? The answer is that a drunken 
debauch is often the exciting cause of an inflammation ; and that they are 
still oftener the producing cause not only of a phlogistic diathesis, but of 
actual subacute inflammation of the mucous membrane of the stomach and 
bowels, of the liver, the eyes, and the brain. Thus intemperance combines 
with gluttony in lighting up inflammation, or in preparing the system for 
the torch of some exciting cause. Every part of the Valley affords evi- 
dence of this fact among its native population ) and in reference to immi- 
grants I may state, that, when in Chicago, in 1844, I was informed by Pro- 
fessor Brainerd, that many of the Norwegians who enter the West by that 
city, die from inflammatory fevers, generated by excessive indulgence in 
meat and whiskey. 

III. Dress. — In the variable climates of our Valley, change of dress is 
required, but the change seldom keeps pace with the necessity. From igno- 
rance or neglect, in numerous instances the modification of apparel is not 
made till the variation of temperature has arrested its pernicious influence. 
In autumn, a resort to warmer clothes is deferred too long ) in spring they 
are thrown off too soon. Children are sometimes reared in such seclusion 
from the elements, that accidental exposures become the cause of inflamma- 
tion j and many grown persons protect themselves so carefully as to be sub- 
ject to attacks of that kind from the least exposure. Others lodge in close 
and heated rooms, whereby they are rendered incapable of exposing them- 
selves to inclemencies of weather, without the risk of an inflammation ; and 
others still, when plunging into fashionable amusements, forget all discre- 
tion and consistency in dress, and thus have serious inflammatory affections 
awakened in their systems. These causes of phlogistic fever, prevail both 
in town and country, but more in the former, where many females adopt 
fashions, which act as predisposing or exciting causes of inflammation in 
certain organs. 

Thus, corseting carried to excess, prevents the normal growth of the 
chest, compresses the lungs and heart, and predisposes them to inflamma- 
tion ) or, so squeezes the stomach between the liver and spleen, as to irritate 
it into chronic gastritis ; while, by pushing the bowels upon the uterine 
system it sinks the latter low in the pelvis, and lays a foundation for future 
inflammations. 



SECTION IV. 

OCCUPATIONS — CASUALTIES — MENTAL CULTIVATION — PASSIONS. 

I. Occupations and Casualties. — Many branches of industry con- 
tribute to the production of the group of diseases we are now considering. 

/ 



662 THE PRINCIPAL DISEASES OF THE 

Sedentary employments with a full diet favor the production of inflamma- 
tions in the brain and abdominal viscera. Constrained positions generate 
cardiac hypertrophies, often accompanied with inflammation and fever. The 
excessive or improper use of the eyes gives rise to ophthalmia. Great mus- 
cular exertion predisposes to lumbago and articular rheumatism. The 
habitual breathing of an atmosphere mechanically impure, produces sub- 
acute bronchitis ; while the accidental inhalation of acrid gases in manufac- 
turing establishments, causes the same disease in its acute forms ; the in- 
gestion of acrid poisons originates gastritis*; burns and scalds inflame the 
skin, and sometimes raise secondary inflammation in the lungs. The whole 
of these remote causes are daily becoming more frequent, as the occupations 
of society become more diversified. Burns and scalds especially are greatly 
on the increase in every part of the country, the causes of which may be 
referred to the following heads : 

1. The invention of certain inflammable terebinthinate alcoholic tinctures 
as a substitute for candles and lamps, the use of which has already destroyed 
many lives, and ought, by law, to be prohibited. 2. The universal substi- 
tution of cotton for woollen fabrics in the exterior winter garments of females, 
which have destroyed a still greater number. 3. The multiplication of 
steam-engines in mills, factories, and boats, where from explosions great 
numbers are annually scalded. 

Mechanical violence, such as contusions, fractures, dislocations, and 
wounds, have always been and still are common causes of inflammation 
among us. The clearing of forest land, and the erection of the houses have 
been unavoidably attended with numerous accidents, producing inflamma- 
tion in various parts of the body. In many parts of our country these 
labors are still in active progress. In others they are succeeded by a new 
and equally prolific source of casualties. I refer to steamboats) which have 
multiplied on our waters till they afford employment to thousands of opera- 
tives, under the name of firemen and deck hands, who are more obnoxious 
to injuries of this kind than any other class of persons. 

In the early settlement of the country, the border warfare with the In- 
dians led to many gunshot wounds; while the warlike spirit which external 
dangers nourished, assumed the character of pugnacity, and led the hardy 
and fearless backwoodsmen to turn upon each other. Both casual and 
pitched battles were common events ; but the state of society was so primi- 
tive, that the instruments of mischief were generally the hands and teeth. 
A pommelling with the first, sufficient to give two or more cases of inflamma- 
tion and fever, was a frequent result; and the injury and loss of an eye, 
followed by the same consequences, was equally common ; while severe bites 
on the face and hands now and then gave poisoned wounds, which healed 
with difficulty. The secretion of an acrid saliva under the influence of rage, 
is an effect, which finds its parallel in the carnivorous animals, and cannot, 
therefore, be rejected as visionary. With the progress of society this pug- 



INTERIOR VALLEY OF NORTH AMERICA. 663 

nacity lias signally abated ; yet enough remains to render it formidable to 
life, for the pistol and the bowie knife, have in many parts of the Valley 
supplanted the teeth and fist. 

The common-place character of the little items of this section, should 
not be regarded as sinking them below the dignity of etiological history, 
which has for its province all causes of disease and death. These are ever 
varying, with variations in the physical and social condition of a country ; 
and without a reference to them, the science of vital statistics becomes but a 
dry assemblage of generalities, inapplicable to any particular time or place, 
and therefore barren of the fruits which society expects from its cultivation. 
As to those with which the section closes, I must be permitted to say, that 
science demands every fact, and historic truth tolerates no suppression. 

II. Mental Exercise and Excited Passion. — Excess of mental 
labor is a predisposing if not a producing cause of inflammatory disease. 
The first corporeal effect of mental labor, falls on the brain, the seat and 
organ of thought. From over action of the mind, the cerebral substance is 
unfavorably affected ; and an increased quantity of blood comes to occupy 
its vessels, which do not always send it forward within the proper time. 

Under the predisposition thus induced, very slight exciting causes may 
awaken an inflammation of that organ, especially in young subjects. This 
cause is more prevalent in the cities than in the country, for the reason that 
hard study is more common in the former than in the latter. For a similar 
reason, the eyes of students are liable to inflammation. The retina is ren- 
dered morbidly sensitive by protracted application, especially at night ; blood 
is invited into it, and not into it only, but, as the tissues of the organ sym- 
pathize with each other, any one or several of them may become the seat of 
congestion and inflammation. 

This does not depend wholly on the use of the eyes, but in part, on the 
frequently induced engorgement of the brain , and is therefore analogous to, 
or identical with, the congestion of the eyes, which attends inflammatory 
affections of the brain in certain forms of fever, or in cerebritis from common 
causes. In latter years it has, in this country, become fashionable to multi- 
ply the studies of children, who, allowed to eat freely, and not required to 
take due exercise, are expected to accomplish their scholastic education in 
half the time which should be devoted to a plan of studies so diversified. 
To say nothing of sinister effects which do not fall under this head, we may 
safely affirm that many children become the victims of this discipline, 
through the simple or scrofulous inflammatory affections of the brain which 
are thus awakened. At the period of adolescence, a chronic irritation of 
that organ thus induced, sometimes raises in the stomach an inflammatory 
condition, with a train of dyspeptic infirmities. 

Excited passions and deep emotions exert an influence on the brain, and 
disturb its circulation. Strong excitation of this kind is more common in the 
southern than the northern portions of our Valley, in the slaveholding than 



664 THE PRINCIPAL DISEASES OF THE 

the non-slaveholding states — but the people of the latter are by no means 
exempt from this cause of cerebral irritation ; for wherever there is den- 
sity of population, with freedom of action, there will be variety of pursuits, 
conflicts of interest, complexity of business, and excited avarice or ambition; 
there must, of necessity, be deep and agitating paroxysms of passion, which 
may awaken cerebral inflammation in the predisposed, while protracted anxie- 
ties, jealousies, and mortifications may create a tendency to the same 
disease. 

III. From this brief, yet comprehensive etiological survey, we perceive 
that the causes which directly, indirectly, or remotely originate the group 
of diseases now under consideration, are immensely numerous and diversified; 
that they abound most in the temperate zone, man's favorite abode ; and 
connect themselves inseparably with his civilization, but for which many of 
them would not have come into existence ; finally, that however various and 
opposite in constitution and character, they concur in the production of a 
common effect, a single type of disease, inflammation and phlogistic fever. 
By living in cities we escape intermittent fever ; yellow fever does not pursue 
us into the country ; capacious and well-aired apartments, cleanliness and a 
generous diet, will nearly protect us from typhous fevers ; vaccination will 
defend us against small-pox, and the other eruptive fevers cannot assail us 
a second time ; but the causes which generate the phlogistic fevers, abound 
in both city and country ; if some be destroyed, others arise ; they increase 
with the density of population ; they beset us on every side ; combine together 
in their action, and generally leave us more liable to a second than we were 
to the first attack. To the physician, philanthropist, and social philosopher, 
these causes, and the fevers they originate, are, therefore, of deep and endur- 
ing interest; for they are checks to the civilization, of which many of 
them are the fruits, and he who may obviate any portion of them, will, in- 
directly, give an impulse to the progress and happiness of society. 



SECTION V. 

PATHOLOGICAL AND MODIFYING CAUSES. 

I. Pathological Causes. — The inflammations which may be referred 
to this head, are not those which make a necessary part of any other disease, 
but such as are produced by it contingently, or occur from its giving effi- 
ciency to exciting causes, that acting on the system during its existence pro- 
duce effects which they might not have produced at other times. It is not 
necessary to make an enumeration of all cases of this kind, and I shall limit 
it to a part of what have occurred under my own observation. 

Inflammation of the brain is sometimes excited by pertussis, which in other 
cases produces bronchitis and even pneumonia ; measles may generate pleu- 
risy, followed by empyema ; active hypertrophy of the left ventricle of the 



INTERIOR VALLEY OF NORTH AMERICA. 665 

heart may generate cerebritis — of the right, pulmonary inflammation j de- 
posits of tubercular matter which may occur without inflammation, inva- 
riably excite it ; a stone in the bladder may originate cystitis ; a retention of 
urine from stricture of the urethra, may lead to rupture of the bladder, fol- 
lowed by a fatal peritonitis ; an abscess of the liver, pouring its contents 
into the cavity of the peritoneum, will produce the same effect, which may 
also be brought about by ulcerative action, perforating the neck of the gall- 
bladder, the stomach, or the bowels, and permitting an escape of their con- 
tents ; suppuration, or rupture of the spleen from softening will do the 
same ; a morbid peristaltic function of the intestines, forming invaginations 
or snarls, may bring about the same result; splenitis, hepatitis, or mucous in- 
flammation of the bowels, may follow on periodical fever ; and subcutaneous 
abscesses on those of a continued type. Finally, all long-continued derange- 
ments of function ; all serious enfeeblement of the nervous system ; every 
deep and protracted impoverishment of the blood, may at last, under the in- 
fluence of exciting causes, or from an inherent tendency in the system to 
reaction, be followed by inflammation. 

II. Modifying Causes. — While all the phlegmasiae consist of inflam- 
mation and fever from common or non-specific causes, they present many 
modifications which demand attention, and justify the classifications of noso- 
logy. The modifying influences may be referred to three different heads : 
1. External or Material; 2. Anatomico- Physiological ; 3. Pathological. 

1. External or Material. — Although, as I have said, the phlogistic fevers 
do not arise from specific but common causes, we must not group the whole, 
and declare them so identical in their nature and effects as to be, in reality, 
but one. Some of their causes awaken an immediate and violent inflamma- 
tion, as great vicissitudes of temperature ; others can only establish an in- 
flammation slowly, as alcoholic drinks and gluttony. Others again, as a 
burn or scald, raise a fever that is less acute, than that which follows on a 
mechanical injury. But the diversities from this source are less striking 
than the diversities which are presented by the fevers which arise from 
specific causes, such as measles and scarlatina. 

2. Anatomico- Physiological. — The modifying influences referable to this 
head, are much greater than the last. Every tissue or organ possessing, 
as it does, a structure, sui generis, not only modifies to some extent the in- 
flammation which may be established in it, but, when inflamed, affects the 
general system in a manner peculiar to itself, though it may not always be 
possible to appreciate the diversity. Inflammations of the osseous and 
cartilaginous structures raise but little fever, and awaken but few sym- 
pathies; dermoid and mucous inflammations are attended with more pain, 
spread a more distressing sympathy through the organism generally, and 
develop an acuter state of fever; inflammations of the fibrous tissue are 
generally attended with a higher degree of pain and fever, as in acute rheu- 
matism, gout, and injuries of the joints from external violence; but 



666 THE PRINCIPAL DISEASES OF THE 

it is when the inflammation attacks a serous or cellular membrane that we 
have the severest suffering in the affected part, and the highest toned phlo- 
gistic action of the general system. Thus peritonitis, pleuritis, and arach- 
nitis, present us with symptoms of great intensity. As a general fact, 
when the inflammation is seated in the investing membranes of the organs, 
it manifests more acuteness, and the accompanying fever has a more open 
phlogistic character, than when it is seated in their parenchyma. This is 
true of hepatic, splenic, pulmonary, and cerebral inflammations. Again, 
the specific or peculiar influence of an organ over the rest, modifies the 
character of the fever connected with its inflammation. When seated in 
the liver, the general symptoms are not the same as when seated in the 
spleen, nor are they the same in an inflammation of the parenchyma of the 
lungs, as in the substance of the brain. In short, it may be said, that 
while all phlogistic fevers are, in one sense, the very same diseases, let the 
inflammation be seated in whatever tissue or organ it may, both it and the 
accompanying fever are modified by the structure, vital properties, and 
functions of the part inflamed. 

The influence of temperament on the character of inflammation and phlo- 
gistic fever may be inferred from what has been already said under the 
head of predisposing causes. The temperament which most predisposes, 
will, of course, sustain the acutest inflammation, et vice versa. 

8. Pathological. — The previous condition of both the general system and 
of the inflamed organ modifies the disease. If the structure be already morbid, 
the inflammation is apt to assume an uncontrollable and destructive cha- 
racter, although it may not rouse as much fever as if the organ had been 
sound; for the sympathies of the general system are more lively with 
healthy parts when inflamed than with such as have their vital properties 
impaired. Thus, the fever connected with pneumonia or pleurisy, in one of 
sound lungs, is more phlogistic than in one whose lungs are tuberculous, 
though the disorganization from the inflammation may be more rapid in the 
former than the latter case. The diversities we are now considering, do not, 
however, spring entirely from the previous state of the affected organ ; but 
still more, perhaps, from the pathological state of the general system before 
the fever commenced. Thus, when the lungs are tuberculous, there is, at 
the same time, such a constitutional distemperature as prevents the develop- 
ment of an acute fever; when the individual, previous to the attack, was scor- 
butic or chlorotic, whatever the part attacked, the phlogistic symptoms cannot 
rise high ; if the patient had been for some time exposed to a malarious atmo- 
sphere, the fever, instead of being sustained, may assume so much of an inter- 
mittent character, as to preclude the use of the lancet ; if a typhous consti- 
tution had been for some time prevalent, that which began as a pure phlogistic 
disease may speedily become typhoid; finally, if jaundice had existed for a 
while, and an inflammation then supervened in the liver or lungs, a state of 
constitutional irritation is soon developed by copious bleeding. Other ex- 



INTERIOR VALLEY OF NORTH AMERICA. 667 

aniples might be given, but these citations will be sufficient to illustrate this 
important and interesting pathological source of the diversities which the 
same phlogistic fevers present to us in practice. 



SECTION VI. 

CAUSES WHICH PRODUCE SPECIFIC PHLEGMASIA. 

I. Thus far this chapter has been devoted to the etiology of those simple, 
every-day inflammations, generally known under the name of phlegmasia, 
which results from the excessive, defective, or misdirected action of the 
agents which support life, which establish a phlogistic diathesis, local and 
constitutional, nearly of the same kind, when the affected tissue is the same, 
which generate the same lesions of structure, and are subdued by one 
method of treatment — the antiphlogistic. I have called them common, 
because, with some undefinable exceptions, one type represents the whole, 
and the causes which produce them are not only familiar objects, but agree 
in their normal actions on our systems, as the necessary means of life and 
health. 

But there are primary inflammations with fever which do not result from 
any of the causes that have been enumerated, which differ widely from each 
other, and from those of which we have spoken, that, respectively, never 
arise but from the same cause, and which are but partially amenable to the 
antiphlogistic treatment. To these we may give as the family name, specific 
or particular. 

The gash of a smooth and polished knife is followed by a common inflam- 
mation ; but if the instrument be smeared with a morbific poison, the in- 
flammation will be peculiar or specific, and the respective constitutional 
affections will, in like manner, differ from each other. Here, then, we have 
representations of the two groups, and some of the causes of the latter group 
are to be enumerated in this section. They may be divided into mineral, 
vegetable, and animal. 

II. When arsenic, iodine, and corrosive sublimate are so administered as 
to excite subacute gastritis with fever, we have three different groups of 
diagnostic symptoms each characteristic of its cause. When these agents 
are taken in large doses, so as produce a sudden and rapidly fatal inflamma- 
tion, the common symptoms so far prevail over the peculiar as to obscure or 
mask them, and hence our practice is to class the mineral poisons with the 
causes of the simple pblegmasise detailed in the preceding sections, which, 
from what has just been said, is obviously wrong. The agents which have 
been named may be taken as specimens of what the inorganic kingdom 
affords, and every reader can augment the number for himself. 

III. The pungent, acrid, and narcotico-acrid vegetable poisons, concur in 
exciting inflammation in the part to which they are adequately applied, 



668 THE PRINCIPAL DISEASES OF THE 

together with fever in the general system. The pathological states produced 
by some of them differ but little from those excited by what we have called 
common causes, but others produce effects of a peculiar kind. Now the 
former, such as capsicum, black pepper, oil of cinnamon, and other spices, 
are mingled with our food, but why are they selected for that purpose ? It 
must be because they make an impression on our vital susceptibilities that 
is both pleasant and salutary.* They constitute the stimulating element of 
our food, and are helps to the sustainers of life. Thus the excitement they 
raise has a fellowship with that created by bread and meat; and it therefore 
follows that when they are accidentally introduced into our stomachs in 
large quantities, they raise an inflammation identical with or very like that 
raised by an abuse of diet, or by any other of those which have been called 
every-day causes. 

When, however, we pass from these to other vegetable substances never 
used as vital sustainers, we find their respective effects peculiar, and that 
they differ as widely from each other as from the ordinary inflammations. 
Thus, elaterium, croton oil, euphorbium, and rhus toxicodendron, not to 
mention others, when applied in an appropriate dose and manner excite 
phlegmasia, each of a special character. 

IV. The animal kingdom supplies many causes of specific inflammation. 
They may be distributed under two heads — normal and abnormal secre- 
tions. 

1. The cantharidin of the coleopterous tribe, and the poisons instilled 
into the wounds made by hornets, wasps, bees, musquitoes, gnats, sand-flies, 
and other insects, are examples drawn from a department of nature, in which 
supplies of virus are substituted for size and strength in the work of self- 
preservation ; and in passing on to a group of larger animals — the serpents 
— we find many of the sluggish and helpless furnished with magazines of 
venom. Now all these normal secretions may cause peculiar inflammations 
with or without fever; and although etiology has not yet condescended to 
distinguish one of these phlegmasiae from another, we have no difficulty in 
recognizing the whole as differing widely from those which are produced by 
agents not malum per se. 

2. We come in the second place to those abnormal or heterologous secre- 
tions which are not only morbid in their origin, but morbific in their effects, 
when applied to our bodies. And here we must be careful to take only 
those which excite inflammation in the part to which they are applied, and 
affect the general organism through that part and by such application. 
Thus limited, we exclude the periodical, continued, eruptive, and all other 
fevers not known to be preceded by inflammation, and out of the residue 
may cite syphilis, gonorrhoea, contagious ophthalmia, malignant pustule, 
glanders, and the disease consequent on dissection wounds. Inoculated 
small-pox and measles cannot be admitted, because those fevers are commu- 

* See vol. i. p. 669-70. 



INTERIOR VALLEY OF NORTH AMERICA. 669 

nicable in other modes, and hydrophobia must be excluded, because the 
wound heals up and the subsequent lesions of function (of a doubtful in- 
flammatory character), are first found in distant organs. 

The etiology of the phlogistic fevers is now concluded but not completed; 
and we must take up the study of their pathology. 



CHAPTER III. 

RISE AND ESTABLISHMENT OF THE SIMPLE OR COMMON PHLEGMASIA, 
AND STATE OF THE BLOOD IN THEM. 



SECTION I. 

OF THEIR RISE AND ESTABLISHMENT. 

I. In the last chapter, on the remote causes of our phlegm asise, there was 
something to give a regional* and national character to the discussion ; but 
when we come to an inquiry into their effects, we are thrown upon the facts and 
doctrines of inflammation and fever, which are the very elements of the science. 
Yet this is not an elementary treatise, nor would I presume to enter the 
list with the great pathologists who have brought this department of medi- 
cine to its present development. Yet, as all sound therapeutics must have 
a pathological basis, it is necessary that I should make a brief recognition 
of such established facts as will throw a reflected, if not a direct and bril- 
liant light on the morbid actions which generate the functional disorders 
and pathological changes which characterize the phlegmasia^. In doing 
this I shall not often stop to trace up to their authors the facts and specu- 
tions which I may select out of what has in a manner become the common 
property of the profession ; trusting, after what has been said, that I shall 
not be charged with intending to present as my own, that which of right 
belongs to others. 

II. The phlegmasise consist essentially of combined inflammation and 
fever, the former always arising before or at the same time with the latter. 
Yet we have inflammations so mild or limited that they do not awaken 
fever. Now may we at any time have fever from the causes which have 
been reviewed, without the other element, inflammation ? I suppose we 
may, and that many of our ephemerae are of that kind. An individual 
after a cold ride, eats but little supper, and drinks freely of any diluent, 
then retires to bed and falls into a perspiration. Another, after a similar 
ride, eats a hearty and stimulating meal with but little dilution, lies down 

* I hope to be pardoned for forming this adjective. In writing on the diseases of a country so exten- 
sive, the words local and topical would he absurd. 



670 THE PRINCIPAL DISEASES OF THE 

to sleep but soon finds himself in a state of febrile heat, with thirst, head- 
ache, and restlessness. Towards morning these symptoms abate, sleep and 
sweat come on, and he rises free from fever. A third, who has subjected 
himself to the same circumstances with the second, may, however, before day 
find that a pleurisy or an articular rheumatism has arisen with the fever, 
which does not then leave him. Thus it appears that a febricula or tran- 
sient fever may be produced by the same causes which generate the perfect 
phlegmasia, but I know of no proofs that a persisting inflammatory fever 
can exist unaccompanied by inflammation. "Without the local affection the 
constitutional soon dies away. 

III. When a cause of inflammation acts upon a part, the immediate effects 
may be either of two kinds : first, if it be applied with moderation, it in- 
creases the vital activity of the part, quickens its susceptibilities, and 
augments its quantity of blood ; which phenomena disappear on its ceasing 
to act ; but if it be renewed, or have not been thus interrupted, the nervo- 
vascular excitement continues to rise ; the sensations, at first pleasurable, 
become painful ; a feeling of heat, with an actual increase of animal tem- 
perature, supervenes ; the hypersemia causes increased redness and swelling, 
and the special function of the part is suspended, or rendered morbid. An 
inflammation is now set up, which may be acute and rapid ; but is oftener 
subacute and chronic, an example of which may be found in common 
inflammatory dyspepsia, from gluttony, or alcoholic stimulation. 

In the production of these phenomena, I recognize the nervous endow- 
ment of the capillary vessels as the tissue first affected, but shall not stop 
to inquire into the comparative probability of the different hypotheses which 
men of genius have invented to account for vascular repletion under the 
previously excited innervation. I see in it the operation of the physio- 
logical law, under which the different organs, when excited by their appro- 
priate stimuli, come to receive a greater quantity of arterial blood than 
when they are at rest ; but how they acquire it, I do not understand. 

The fever which ensues is equally referable to another law of the 
organism; that which through the nervous system gives to a part the power 
of modifying the whole. Thus, when the stomach is excited with food and 
stimulating drink, the brain and heart are quickened in their activity and 
energy, and thus the whole system is brought into a state of excitement, 
which strongly contrasts with its condition when that organ has been for 
some time deprived of aliment. Under this law, when a part becomes in- 
flamed, it raises in the organism a morbid excitement or fever, the intensity 
of which is generally in proportion to the extent and violence of the inflam- 
mation multiplied into, that is, taken in connection with the influence 
which the organ in its states of healthy excitement exercises over the rest. 

IV. But causes do not always act on a part in the manner that has been 
pointed out. In numerous instances they come with concentrated and vio- 
lent energy, when, instead of exciting, they directly depress the nervous 



INTERIOR VALLEY OF NORTH AMERICA. 671 

force, reduce the amount of blood below the normal quantity, and suspend 
or greatly impair its special functions. The length of time it may continue 
in this state of depression will be according to the degree to which it has 
been carried, and the recuperative powers of the organism. When the 
former is great and the latter are small, the patient may sink without a 
supervening inflammation ; but under the physiological law of reaction, the 
vital energies may at length revive. "When this occurs, the renewed excite- 
ment of the part is sometimes so little changed in kind, and rises so slightly 
above the normal standard, that its healthy functions are speedily restored. 
When not thus restricted, an excessive, local, morbid excitement ensues, 
with phenomena of inflammation so like those produced in the other mode, 
as not to be distinguishable from them. The fever is gotten up under the 
law already announced, but the mode is more complex, and the subsequent 
progress of the case less simple. Thus, when the part is smitten and 
brought low in its vital energies, the whole organism feels the effect, and 
constitutional enfeeblement is added to local. The system has, of course, 
to rise from this condition, or death would occur without fever. "When the 
general reaction takes place, the excitement may not be much perverted, 
nor exalted beyond physiological limits, or it may be both perverted and 
excessive, which constitutes it inflammatory fever. The circumstance which 
gives to cases of this kind the complexity of which I have spoken is this. 
During the depression, some organ, not reached by the remote cause, but 
participant in the general depression, may become the seat of passive con- 
gestion, and when the reaction takes place, of inflammation. 

But we must stop here. A perfect phlogistic fever may be generated 
with any surface on which the remote cause has acted becoming inflamed. 
Such surface has merely been the medium through which the organism has 
been brought into a state of depression, and when reaction occurs, no inflam- 
mation may appear in it, but in some deeply-seated or sequestered organ ; 
and this is undoubtedly very often the case, the seat of the inflammation 
being generally some part that was previously infirm, in a state of morbid 
sensibility, of languid circulation, or from a phlogistic diathesis about to 
pass into inflammation. Thus it is that changes of weather, acting on the 
skin and mucous membranes of the lungs, awaken inflammation in the 
pleura, the peritoneum, or the joints. In these cases, the inflammation and 
the fever — different parts of one reaction — may arise at the same time, or 
either may take precedence, for a brief period, of the other. 

V. We have already recognized an enervated state of the body from 
previous disease, a poorly nourished frame, an organism rendered feeble by 
close housing, and a degradation of the functions from sedentary employ- 
ments carried on in cold, damp, and unventilated apartments, as among the 
predisposing causes of phlegmasia. Sometimes, perhaps, they are pro- 
ducing causes; but in general exciting agents are required, which throw, 
and that readily, too, the innervation and circulation into the state above 



672 THE PRINCIPAL DISEASES OF THE 

* 

described, out of which inflammation and fever arise, notwithstanding the 
causes might have been altogether insufficient to produce depression in a 
sound and vigorous system. Thus it is that those who seem to be most 
secure from the phlegmasise, are, if subjected to the action of exciting causes, 
most likely to suffer with them. The inflammations thus generated are, in 
many cases, from the low state of the vital forces previously existing, of a 
subacute or sluggish character, approaching to simple congestions; but, 
under the influence of powerful exciting causes, they are sometimes acute, 
destructive, and dangerous, in proportion to the pre-existing infirmities of 
the patient. These infirmities may prevent the development of striking 
morbid phenomena, yet the work of destruction will not be less, but even 
the more certain ; as the dry leaves of our woods in autumn are speedily 
consumed, without sending forth the more conspicuous flame of the sturdy 
and slowly burning trees. 

VI. It remains to speak of the opposite predisposition, characterized by 
abundance of rich blood, and a vigorous state of the solids. The system 
is then rising into super-excitement, and the upward impulse given it even 
by a slight exciting cause, as a gust of passion, a debauch, the over-exer- 
tion of an hour, or a limited change of weather, may establish inflammation 
and fever, without previous depression, or with that which is both inconside- 
rable and transient. Some organ which already received as much blood as 
it could transform and transmit, now becomes oppressed, and a sudden 
change of function takes place, from nutrition and special secretion, to the 
morbid products of inflammation. The phlegmasia thus originated, mani- 
fest themselves by violent symptoms, and demand early and active antiphlo- 
gistic treatment ; under which, however, they yield with greater certainty, 
than those which are rooted in constitutions of a deranged and feeble 
kind. 

Having considered (historically) the different modes in which the phleg- 
masiae arise, let us briefly inquire by the light of facts into their intrinsic 
nature. This may be done under the two heads of inflammation and 
fever. 

VII. In the inflamed part there is not an abolition or even reduction of 
the innervation, on the contrary, it is morbidly active, as far at least as the 
production of sensation is concerned; nor is there a diminution, but an 
excess of blood, without which indeed the phenomena of inflammation 
could not exist. The calefacient function, depending apparently on nervous 
influence and the presence of arterial blood, is augmented in activity, the 
circulation through the central parts of the inflamed organ or tissue is 
arrested, but increased in velocity and volume through the circumferential; 
the function of nutrition is suspended, and whatever special secretory func- 
tion the part may perform is suppressed or perverted in mode, yet the struc- 
ture is not idle, for other secretory actions are set up, and frequently pro- 
ceed with great activity. In this morbid condition, the danger to the struc- 



INTERIOR VALLEY OF NORTH AMERICA. 673 

ture is twofold : first, from the lesion of the innervation j second, from 
the suspension of nutrition, which favors softening; third, from the infiltra- 
tions of the new secretions into the affected tissues. Should the organ be 
one of high rank, the state in which we now find it may destroy life in two 
concurrent modes : first, by the sympathy of the other parts of the organism 
in its sufferings, which is effected through the nervous system ; second, by 
its becoming totally disqualified for the discharge of its special function, 
when others dependent on or linked with it, can no longer perform theirs. 

VIII. When we turn from the part in a state of inflammation to any part 
in a state of fever, we find the innervation in that morbid condition which 
renders all the healthful stimulants of the nervous system disagreeable ; 
their sensibility is not diminished but rather increased, for aches and pains 
with physical impatience and restlessness prevail ; the calefacient function 
is moreover augmented in its activity ; all the special functions of secretion 
are interrupted or perverted, and the function of nutrition is suspended, as 
appears from the fact, that the patient comes out of the attack in a state of 
emaciation proportionate to its intensity or duration. We find also that in- 
flammations may arise in new parts, either from their sympathy with the 
organ first affected, or from the momentum given the blood by the heart, 
which seems as it were to have appropriated to itself the contractility of 
the apparatus of locomotion, now in a state of enfeeblement, corresponding 
inversely to the intensity of the fever, and the force of the central organ 
of the circulation. The reactive influence of this condition on the inflamed 
organ is pernicious, and, at the same time, as it exhausts the energies of 
the organism, and takes away its capability of bearing up against the de- 
pressing influence of the inflammation, we need not wonder that such an 
attack may at an early period prove fatal. 

We must turn from the state of the solids, and the distribution of the 
blood, to the condition of that fluid in the phlegmasia, and in doing this 
I must avail myself of such researches as have lately, and but lately, been 
made by the chemico-pathologists of Europe, whose greater means and op- 
portunities of experimental inquiry, not less than their profounder science, 
have made them our teachers. As I am writing for my own scattered and 
insulated countrymen, many of whom have never seen the researches to 
which I allude, I shall give to this article an extension, which otherwise 
would not be demanded. 



SECTION II. 

CONDITION OP THE BLOOD IN THE PHLEGMASIA. 

I. The Fibrine. — Every medical practitioner knows, that in phlogistic 
fevers, the drawn blood, on coagulating, exhibits on its surface a buffy or 
vol. ii. 43 



674 THE PRINCIPAL DISEASES OF THE 

sizy coat. This crust, consisting of fibrine arranged into a membrane, 
smooth on the surface, but dipping into the clot, is never absent when the 
inflammation is sufficiently extensive or intense to excite fever; perhaps 
even when below the degree which can disturb tbe organism at large. Bub 
while its absence would prove that inflammation does not exist, its presence 
does not necessarily imply that pathological state; for, as we shall hereafter 
see, there are conditions of the blood, which lead to its formation indepen- 
dently of inflammation or fever. For this crust to show itself, it is neces- 
sary, that the relative physiological proportions of fibrine and red corpus- 
cles should be changed. An increase of both, or a decrease of both in 
the same ratio, will not produce it; but an augmentation of the former, 
while the latter remains normal, or a decrease of the red corpuscles, while 
the fibrine continues undiminished, originates it; and the thickness of the 
crust, coeteris paribus, will be in proportion to the loss of physiological 
balance between the two proximate elements, and to the absolute quantity 
of fibrine. 

Thus, if its quantity should rise to a maximum, the red corpuscles re- 
maining undiminished, the thickness of the buffy coat should be greater 
than if it remained normal, and the same loss of physiological proportion 
resulted from a reduction of the red corpuscles. Finally, it would attain 
its greatest thickness under a simultaneous increase of fibrine and decrease 
of the corpuscles. 

I was long since convinced that the current theory of the buffy coat being 
merely the effect of a slower coagulation of the blood, thus allowing time 
for the heavier, colored corpuscles to subside, was, as an explanation of the 
whole phenomenon, defective ; for, 1st, T have often witnessed an earlier 
coagulation of inflammatory than of healthy blood; though I admit that 
the reverse is generally the case ; 2d. An experienced eye can generally 
predict, while the blood is still flowing, that it will throw up a sizy covering, 
from observing a peculiar dun, slate, or leaden hue, which seems to result 
from an immediate precipitation of a portion of the corpuscles, and a con- 
sequent diminution of the red color of the surface/ composed, as it then 
chiefly is, of the liquid fibrine or the liquor sanguinis. The hypothesis 
suggested by this observation was, that inflammation increases the specific 
gravity of the red corpuscles, diminishes that of the fibrine, and establishes 
between them a divellent tendency ; or bestows on the corpuscular element 
a greater attraction of aggregation, which might follow as a consequence of 
a diminished attraction for the fibrinous element. 

Without pursuing these speculations, the last of which has lately been 
supported by several able physiologists,* we may come at once to an in- 
creased production of fibrine, as the great cause of the buffy coat in the phlo- 
gistic fevers. Although not the first to discover this condition, Andral, and 

* Alison's Outlines of Physiology. Carpenter's Human Physiology. 



INTERIOR VALLEY OP NORTH AMERICA. 675 

his coadjutor, Gavarret, have, by a long and careful series of experiments, 
given us the most exact information concerning it.* After many analyses 
of healthy blood, they came to the conclusion that, in Paris, three parts in 
a thousand may be taken as the average quantity of fibrine, and by this stan- 
dard they measured the results of their experiments on the blood of patients 
laboring under phlogistic fevers. In every instance they found the quantity 
of fibrine to rise above this number. In mild inflammations, the increase 
was small, but in the intense it was from 200 to 300 per cent., that is, to 
amounts indicated by 6, 9, and 12, that of normal blood being 3. From 
their Essay, and the " Chemistry of Man," by Simon, I have collected two 
hundred observations, which give an average that is within a fraction of 7; 
so that we may conclude that in the phlogistic fevers of the continent of 
Europe, the common increase of fibrine is about 133 per cent. With such 
an augmentation of this element of the blood, its slower coagulation (an 
admitted phenomenon, to which, however, as we have seen, there are ex- 
ceptions), appears remarkable, as the opposite might be expected. In 
explanation of the anomaly, Andral has suggested, that the new fibrine is 
less coagulable than the old, and that its presence occasions a slower coagu- 
lation; and in the present state of our knowledge, no better explanation 
can perhaps be offered. In different cases the firmness of the buffy coat 
displays considerable variation, not resulting merely from its thickness, but 
from the cohesion of its particles. This may in part depend on the quality 
of the fibrine, in part, perhaps, on the presence of entangled red corpuscles. 
When the cohesive attraction is great, the surface of the clot becomes 
cupped. In estimating the grade of inflammation, by the amount and com- 
pactness of the buffy coat, the physician must bear in mind, that if the 
blood flow into a deep and narrow vessel, that coat will be thicker than if 
the vessel be broad; that if it be metallic the coagulation will be quickened; 
finally, that its flowing guttatim, or in a small or feeble stream, will diminish 
the amount of buff. When it is a question, whether inflammation exist, or 
venesection should be repeated, these circumstances acquire considerable 
importance. We must not suppose that in phlogistic blood, all the fibrine 
is found in the buff, for it extends in an open network throughout the coagu- 
lum, which, indeed, but for its presence would have no existence ; inasmuch 
as the corpuscles would fall and constitute a stratum in the bottom of the 
bowl. Andral has sought to determine the relative quantities of fibrine in 
the buffy coat and the coagulum beneath. In five patients, three with 
pneumonia and two with rheumatism, the average results were, buffy coat 
6-64, clot beneath 2-05; so that more than three-fourths are found in the 
former. 

To the condition of the blood we have been considering, Simon has applied 
the term hyperinosis.^ 

* Essay on the Blood in Disease, Phil., 1844. 

t Formed of Greek words, signifying excess of flesh or the fibre of flesh. 



676 THE PRINCIPAL DISEASES OP THE 

II. The Red Corpuscles. — According to Andral,* the corpuscles, in 
healthy blood, make one hundred and twenty-seven parts in a thousand, or 
forty-two times as much as the fibrine. His experiments have led him to 
the conclusion that they are neither increased nor diminished by these 
fevers ; but Simonf declares that they are diminished. Unable to consult 
the original tables of the former,! I am obliged to rely on certain abstracts 
from them, incorporated with his own results and those of other German 
experimenters, by Simon. With as much care as possible, I have collected 
fifty-five cases of first bleedings, in which the amount of corpuscles is stated 
in connection with the amount of fibrine, and the following are the averages: 



Andral and Gavarret, 40 first bleedings, . 5-38 fibrine, . 113-84 corpuscles, 

Simon, and others, 15 " " . 5-95 " . 92 05 

Mean of . 55 " " . 5-72 " . 107-90 " 

Mean of healthy blood, .... 3-00 " . 12700 " 

Cases in which the corpuscles rose above the healthy mean, 13. 

Highest of the whole, 148-80 

. Lowest of the whole, , 42-08 

Cases in which the reduction was so small as not to be 

below a physiological mean range, say, . . . . 120=10. 

From this table it appears that the phlogistic fevers commonly diminish 
the corpuscular element; but that they may exist without producing that 
effect. Thus, in ten cases, the numbers expressing them varied from 120 
to 127, which may be regarded as within physiological limits; and in thirteen, 
the number was so far above 127, as to give an average of 137*76, or 10-76 
more than the normal quantity, 127. The effect of the phlegmasia upon 
the corpuscles is, tjben, far from being uniform, as they may exist with a 
normal, an increased, or a diminished quantity of that element, while, as 
we have seen, they are always accompanied by increase of fibrine. But a 
different, and, perhaps, better view may be taken of this matter. The phy- 
siological range of the numbers which express the corpuscles is wide, and it 
may be that in all the cases in which they were found above the standard 
of health on first bleeding, they had been still higher, previously to the 
attack, and were then undergoing reductions, and with the fact before us, 
that in fifty-five cases, their average aggregate was 19-10 below the healthy 
number, 127, we are, perhaps, required to conclude that while the phlogistic 
fevers increase the amount of fibrine, they diminish that of the corpuscles. 

However this may be, it is unquestionable that in the progress of these 
fevers, the corpuscles do undergo a signal reduction. If the conclusion to 
which we have just come be admitted, this reduction is no doubt owing in 
part to the direct influence of the fever ; but there is another and much 
more operative cause — the bloodletting employed for its cure. The pro- 

* Essay, p. 61. f Chem. of Man, p. 207. % Annales de Chimie et Physique. 



INTERIOR VALLEY OF NORTH AMERICA. 677 

fession is familiar with the fact, that while venesection, practised for the 
cure of these fevers, leaves the proportion of fibrine unaffected, it rapidly 
reduces the quantity of the corpuscles. This will appear still more con- 
clusively from the following table, compiled from results collected with 
those which have just been given. 

TABLE. 

Mean of 55 first bleedings, . . 5-72 fibrine, . 107-90 corpuscles. 

Mean of 23 second " . . 5-94 " . 105-22 " 

Mean of 10 third " . . 6-97 " . 99-34 " 

Mean of 12 fourth and fifth bleedings, 7-84 " . 95-08 " 

Several reflections and conclusions are suggested by this table. 

1. It may be said that the reduction in the amount of corpuscles which 
it presents, is owing entirely to the influence of the fever ; but as venesec- 
tion produces that effect in health, we cannot doubt its influence here ; and 
hence there are two causes operating on the phlegmasia^ — one pathological, 
the other therapeutic — to cause such reduction. Of the irrelative agency, it 
is impossible to speak. The former may or may not be according to the 
intensity of the fever, the latter is in proportion to the amount of blood 
drawn. 

2. It is familiar to all physicians that, in many of the phlegmasia, the 
blood first drawn is not buffy. In these cases, we may suppose the cause 
to be twofold : 1st. The fibrine has not yet been augmented to any great 
degree ; 2d. The corpuscles are still abundant. In other words, the proportion 
between them is not such as to favor the production of the buffy coat. A 
second bleeding, only a few hours after the first, may present it, because the 
previous loss of blood, has reduced the number of corpuscles. 

3. In the chronic phlegmasia — I have seen it in rheumatism and me- 
tritis — after repeated and (for some time) copious venesection, the blood 
still remains sizy and cupped, while the coagulum is very small. In these 
cases, which, formerly, I did not understand, the buffy blood is no longer 
the exponent or sign of inflammation, as it was in the beginning, but of a 
greatly reduced volume of the corpuscles. 

4. We are all aware that if bloodletting be carried beyond the necessary 
degree in the treatment of the acute phlegmasia, a state of constitutional 
irritation is induced, which essentially resembles the hysterical affection of 
chlorotic girls, and women of a lymphatic temperament, in the time of the 
final cessation of the menses. In all these cases a great reduction in the 
red corpuscles is the negative cause of the perturbation of the nervous 
system ; and all may show buffy blood, not from an increase of fibrine, but a 
decrease of corpuscles. I presume there are not many physicians who have 
failed to meet with this appearance of the blood after very copious depletion, 
suggesting that the inflammation was still raging, although unquestionable 



678 THE PRINCIPAL DISEASES OF THE 

signs of constitutional irritation, indicative of a change of diathesis, had 
been developed. We are indebted to the researches of modern haemato- 
logists for the elucidation of this obscure pathological condition. 

III. The Serum. — The average quantity of water in the serum of the blood 
in the phlegmasia, according to sixty-six experiments by Andral and Gavarret, 
was 801-00, that of healthy serum being 790 ; thus in the phlegmasia, this 
element is increased eleven-thousandths above the normal standard. This 
augmentation is doubtless owing to the reduced renal, and (almost suspended) 
perspiratory secretions. The solid ingredients of the serum are likewise 
increased. Thus in fifty-seven of Andral's cases, the solid residue of the 
serum amounted on an average to 83-77, that of the healthy fluid being 80. 
It is not known whether this increase is in the saline or the organic princi- 
ples of that fluid. A diminution in the secretion of urine, so commonly 
attendant on the phlegmasias, would suggest an accumulation in the blood 
of its saline principles; but whether the addition of 3-77 parts to the 
solid residue is from that source, or there is also an increase of albumen, is 
unknown. We are, I think, at liberty to conclude, that in the phlegmasiae 
the latter animal principle is not diminished, but may be a little increased. 
Whatever modification in the chemical elements of the serum may take place 
its alkaline reaction still continues. The serum which is effused into the 
cellular and serous cavities when inflamed, is said by Andral to contain less 
albumen than that which remains behind. 

IV. Fatty and Extractive Matters. — The fat is declared by Simon* 
to be increased in the phlegmasise ; but neither his own facts nor those in- 
troduced by his translator, Dr. Day, bear out the assertion. Nothing seems 
to be known concerning the state of what have been named the extractive 
matters, in the blood of those laboring under the phlegmasia ; but it can- 
not be doubted, that they suffer modification. Indeed, when we observe the 
changes which occur in the quantity if not in the quality of the fibrine and 
corpuscles, it is difficult not to believe, that many others, affecting per- 
haps the whole constitution of that fluid, take place. Where so many 
elements are united, and so many isomeric changes are every moment 
taking place, it appears quite impossible, if one element should be modified 
by disease, that the others should continue unaffected. But the time is pro- 
bably distant, when a thorough knowledge of the condition of the blood in 
these or any other fevers, will be acquired. The delicacy and difficulty of 
the chemical manipulations necessary to such inquiries, place them beyond 
the reach of the mere physician, especially if resident in a newly settled 
country ; and leave the field to be occupied by a comparatively small number. 

* Chem. of Man, p. 206. 



INTERIOR VALLEY OF NORTH AMERICA. 679 

SECTION III. 

SPECULATIONS ON THE PRODUCTION OP' HYPERINOSIS. 

Inflammation is the only known disease in which the hyperinosis of 
the blood is found, not the only one in which a buffy coat appears, for we 
must bear in mind a certain reduction in the amount of corpuscles, will 
lead to the production of the buffy coat, even when a state of hyperinosis 
or deficient fibrine exists. Now is inflammation a cause as well as an inva- 
riable accompaniment of excess of fibrine ? May it not be an effect, and 
may not the disease have its origin in the blood ? "With the best patholo- 
gists, I think the latter opinion untenable, for — 1st. A very rapid develop- 
ment of fibrine takes place with the rise of inflammation in a part subjected 
to mechanical injury, the individual up to the time having been in perfect 
health. 2d. Every physician has seen the supervention of inflammation in 
the brain or lungs, for example, in typhous fevers, which are accompanied 
as already shown by hyperinosis or deficient fibrine. 3d. It has often hap- 
pened to physicians to bleed patients and observe no buff, immediately 
before they have been attacked by some acute inflammation, which, however, 
gave to the blood, when drawn, soon afterwards the characteristic crust. 
These observations appear to be conclusive against the hypothesis that hy- 
perinosis causes inflammation. We are compelled then to regard it as either 
solely a product of that pathological state ; or of that and the disorder in 
the organism, generally occasioned by, or accompanying it — in other words 
of the fever. The determination of the question how far the fever concurs ? 
is not without difficulty; for the reason that an inflammation of such limited 
extent or violence as not to awaken some degree of fever, could not be 
expected to increase the fibrine of the blood, so far as to make it appreciable ; 
and whenever it becomes more intense, a constitutional disturbance which 
augments pari passu with the inflammation, is the inevitable effect. If 
either abates, the inordinate development of fibrine likewise abates ; but this 
decides nothing, inasmuch as a mitigation or subdual of one, is necessarily 
accompanied by a corresponding abatement of the other. 

Whatever may be the participation of the general system in the produc- 
tion of hyperinosis, it cannot I think be denied that the inflamed part is a 
chief seat of its elaboration. This is demonstrated by the great amount 
which is effused into its parenchyma, or upon its surface, where it begins 
with the dawn of heat and redness, and continues to the final cicatrization, 
if the inflammation should not be resolved. An inflamed part is indeed a 
gland, one of the secretions of which is the liquor sanguinis, or fibrine dis- 
solved in serum. 

Now, can we suppose that the excess of fibrine contained in the whole mass 
of blood is here elaborated and carried out by the circulation ? I think we 



680 THE PRINCIPAL DISEASES OP THE 

cannot; for — 1st. The circulation through the inflamed organ is, as we have 
already seen, suspended or greatly retarded, a condition unfavorable to the 
egress of fibrine from it into the general circulation. 2d. A very limited 
inflammation seated in a highly vitalized and sensible part, will produce or 
is attended by an acute fever, in which the number for the fibrine will be 
high. May we not then ascribe to the fever itself a participation in the 
production of hyperinosis ? They who might reply in the negative would 
rely on the fact, that we have fevers — intermittent, typhous, and eruptive, 
which are sometimes intense, but do not generate fibrine. But shall we 
conduct the argument, and rest our conclusion on a single analogy ? Are 
there not specific types of fever ? Are not the exhalations from the body 
of one in the eruptive stage of small-pox, so different from those in measles, 
as that one will produce in those exposed a pustular, the other a papular 
eruption ; and do not these exhalations in both differ essentially from those 
of a typhous patient, which produce neither small-pox nor measles, but a 
continued fever of a different kind, and do not the exhalations from the 
whole, differ from those in autumnal or yellow fever ? In all these cases the 
exhalations are from the whole body, elaborated in it, and not dependent on 
the morbid action in a particular part. Now the exhalations of which I 
have spoken are derived from the blood, and imply transformation or meta- 
morphosis of some of its materials ; and if this can occur under the in- 
fluence of these fevers, why may not a different modification of the princi- 
ples of the blood, resulting in a state of hyperinosis, or excess of fibrine 
occur in the phlogistic fevers ? If a gaseous poison can be exhaled from 
the whole body, in the eruptive fever of small-pox, that is precisely of the 
same nature with that secreted subsequently at a particular inflamed spot in 
the skin, why may not fibrine be generated in the phlogistic fevers, in the 
whole circulation as well as in the inflamed organ ? I do not perceive that 
any reason could be assigned why it cannot, and am brought therefore to 
the conclusion , that the system at large may co-operate with an inflamed 
part in the production of fibrine. This, however, does not prove that it 
does so co-operate, nevertheless it prepares the way for such a conclusion ; 
in proceeding to which, I ask the question, whether on physiological prin- 
ciples, the general system ought not, or might not be expected, thus to con- 
cur with the inflamed part ? Such concurrence it appears to me should be con- 
sidered natural. It is natural for a part to spread the mode of action which is 
established in it, throughout the whole. An atom of variolous poison inserted 
in the skin, brings the organism at large into the same type of morbid action 
with the point to which it is applied. This it must do in one of two modes : 
by acting on the blood, or on the nervous system. Now both of these modes 
are open to the inflamed organ. It may cause a commencement of changes 
in the blood, which may be adopted and continued by the whole system - y 
or it may reach the system through the medium of the nerves ; or the two 
modes may be combined. The extension of the influence of the inflamed 



INTERIOR VALLEY OF NORTH AMERICA. 681 

organ, I suppose to be through the innervation. Modified in the part 
affected, the state of the nervous system becomes modified throughout the 
whole organism, and this constitutes the basis of the phlogistic diathesis, 
the full development of which is found in the increased momentum of the 
circulation, and augmented production of fibrine. That the circulation can 
be exalted or depressed, nutrition increased or retarded, and the various 
secretions promoted, suppressed, or perverted, by modifying the innervation, 
are facts which can neither be denied nor explaiued. 

In the diseases under consideration, all the influences of the nervous sys- 
tem tend to the creation of excitement — to the getting up of an inflammatory 
organism, in harmony with that of the affected part. It is not difficult to 
perceive why all this should happen, nor impossible to perceive its final 
cause. Inflammation, notwithstanding its destructive ravages, is in fact a 
reparative process, and under a great variety of lesions, a sine qua non, to 
the preservation of life. In all such cases it is essentially physiological, 
and fibrine is the material which it generates and applies to the end to be 
accomplished. It is equally physiological, that the apparatus of the circu- 
lation at large should co-operate with the blood itself, and in many severe 
injuries, unless they do, the patient sinks. The whole must aid the part, 
or it cannot recover. 

I am aware that reparation of injury may be effected without inflamma- 
tion, but have always seen it confined to simple and limited solutions of 
continuity, unattended with contusion, laceration, or the introduction into 
the wound of any foreign matters. Every physician knows that in a few 
hours after venesection, he may pull open the orifice and let the blood flow 
anew, after which reunion seldom takes place without some degree of inflam- 
mation; but if he postpone the second bleeding till the next day, he must 
make a new incision, for then he will find the first quite healed up without 
any sign or feeling of inflammation having existed. In this case the orga- 
nization of the stratum of fibrine between the sides of the wound is instan- 
taneous, and the integrity of the part is restored. 

We are familiar with other examples of the union of fibrine to the tissues 
with which it may happen to be in contact. Thus the blood of an artery 
between a ligature and the first branch above, has its fibrine united to the 
parietes of the vessel, which from a hollow is thus transformed into a solid 
cylinder, apparently without the intervention of inflammation. But here 
the parts may be said to be in a physiological condition. Another example 
is the adhesion, often of a decided kind, between the columnae carneae of the 
heart and portions of the coagulum of fibrine, known in the dissecting room 
under the name of polypus. This coagulation and adhesion takes place, no 
doubt, before, not after death, and appears to occur independently of endo- 
carditis, though, perhaps, is chiefly found in cases whose development of 
fibrine is great. But the conditions favorable to the healing of wounds with- 
out inflammation seldom concur, and whenever the wound is extensive, two 



682 THE PRINCIPAL DISEASES OF THE 

other conditions, well calculated to preclude such a desirable result, are pro- 
duced. 1st. The hemorrhage, after the lips of the wound are compressed, 
will keep some portion of its sides from contact, and the serum and red 
corpuscles have to be removed by absorption. 2d. The shock given to the 
part by the instrument of violence, depresses its vital powers, and reaction 
is the natural effect. That reaction, whenever accompanied by hyperasinia, 
is inflammation. Dr. Macartney* insists, that a reaction of such a grade as 
to constitute inflammation is not necessary; but rather injurious to the ob- 
ject in view. It would be more correct to say that the inflammation may 
rise beyond the required degree, and is then unfavorable. It is the duty of 
the surgeon to restrain but not prevent it entirely. Should he attempt the 
latter he would perhaps not often succeed, and when he did, his interference 
might so keep down the natural reaction, that no adhesion would take place 
notwithstanding the presence of fibrine. That inflammation of a surface is 
favorable to its union with another surface is proved by the fact that the 
coagulating lymph thrown out in pleurisy and peritonitis, is often found to 
invest the lungs and the abdominal viscera without occasioning their adhe- 
sion to the parietes of the chest and abdomen, simply because their lining 
membranes were not inflamed. As a hot and cold piece of iron cannot be 
welded, so as a general fact a certain amount of inflammation is necessary 
in both cut surfaces to effect their union. 

It remains to consider how either the inflamed part or the system at large 
generates the new fibrine. "We may safely assume that there is but one 
process by which this element can be prepared, and, therefore, that the new 
fibrine is formed out of the same or analogous materials, and by the same 
chemico-vital action with that previously existing. That natural function 
is then more active in the phlogistic fevers than in health, and produces a 
quasi hypertrophy of this element of the blood ; a view that is in keeping 
with those just taken, and confirmatory of the theory that the phlogistic 
fevers, both in the constitutional and local affection, depart less from a phy- 
siological type than the other groups, which depend on specific morbid 
poisons, while these depend on the irregular, excessive, or defective action 
of the agents which are the ordinary supporters of life. 

But whence comes the fibrine of healthy blood ? Undoubtedly from our 
food, for it is detected in the chyle after it has passed through the mesenteric 
ganglia, if not before. But in the phlogistic fevers, food is withheld or 
the digestion of it is suspended ; the supply through the thoracic duct is 
therefore interrupted, and, a priori, we should expect its amount in 
the blood to be diminished instead of being increased. The increase then 
must be out of and at the expense of some other protein element of the 
blood. Now, the others are the albumen of the serum, and the transparent 
globuline of the red corpuscles, regarded by Simon as a peculiar form of 
caseine, very nearly related to fibrine. Now, the researches of Andral and 

* Treatise on Inflammation. 



INTERIOR VALLEY OF NORTH AMERICA. 683 

Gavarret have shown, that in the phlogistic fevers there is no reduction 
but rather an increase in the solid ingredients of the serum, of which the 
albumen is the chief; and we cannot, therefore, conclude that the increase 
of fibrine is at the expense of the albumen. On the other hand, as we have 
seen (p. 110), there is a reduction in the corpuscles, amountiDg, at the time 
of the first bleeding, in fifty-five experiments, to the average of 19-10 parts 
out of 127 ', which loss was found greater, at subsequent bleedings, until it 
rose to 32 parts of 127, when the fibrine has risen from 5-72 to 7-84. 

Is it not, then, highly probable, that the transparent portion of the red 
corpuscles (globuline) is the material out of which the organism elaborates 
the new fibrine in the phlegmasiae ? And may it not be, as Simon has sug- 
gested (p. 292, Am. Ed.), that the fibrine found in the chyle is formed from the 
blood in the ganglia of the mesentery ? This speculation, it will be perceived, 
carries with it the hypotheses, that the blood globules are formed before the 
fibrine, that the material for the latter, in the condition of globuline, is first 
subjected to the action of the air in the lungs, and afterwards converted by 
isometric chemico-vital action into fibrine, for the formation and reparation 
of the tissues. In its transition from globuline to fibrine, it probably dis- 
plays itself in the blood in a corpuscular form, constituting the white or 
colorless corpuscles, at all times to be observed, but more abundant in the 
phlogistic fevers than in health, and, above all, most numerous in the blood 
of the inflamed part.* [The progress of investigation has proved that this 
increase in the relative quantity <jf the white corpuscles in inflammation is 
by no means constant, and that it occurs independently of that morbid con- 
dition, especially in cachectic subjects, in whom the liver, spleen, and 
lymphatic glands are enlarged, or otherwise diseased, and the diathesis is 
tuberculous. Professor J. H. Bennett has directed the attention of the 
profession to this disordered condition, which he has termed Leucocythasrnia 
— white cell-blood. — Ed.] 

But, from whatever source derived, we may conclude that the fibrine 
exerts a sustaining or exciting influence on the system • for in the adynamic 
fevers it is deficient in quantity. If such be its effects, its increase in the 
phlogistic fevers must be a source of aggravation. And this may explain 
several things not so explicable, perhaps, on any other hypothesis. 1st. Why 
they increase in violence independently of all external causes. The aug- 
mentation of the fibrine is the augmentation of an internal stimulus, which 
is not a poison but one of the sustainers of life, and, as we have already 
seen, the phlegmasiae are produced by causes of that class. 2d. Why food 
is so much more pernicious in these fevers than others. It supplies new 
materials for the manufacture of fibrine. 3d. The great value of blood- 
letting, which, independently of other modes of action, diminishes not only 
the amount of fibrine in the bloodvessels, but the material out of which it is 

* Carpenter's Physiology, p. 423. 



684 THE PRINCIPAL DISEASES OF THE 

formed. 4th. The great value of water, which serves to dilute the fibrinous 
plasma, and render it less exciting to the internal surface of the vessels. 

Speculations which thus conform in their practical requirements, to what 
the experience of all ages has shown to be necessary, have at least the 
negative merit of being harmless. 



CHAPTER IV. 

PROGRESS, TERMINATIONS, AND ANATOMICAL LESIONS OF THE 
SIMPLE PHLEGMASIA. 



SECTION I. 

PROGRESS AND TERMINATIONS. 

An inflamed organ has not unaptly been called a gland. Yet, although 
in health, it might have been a part which did not pour out a fluid, it was 
even then a gland ; for while it passed forward the blood sent to it (a func- 
tion of every vascular part), it took from that fluid, by endosmosis, the 
serum which lubricated its cells and surfaces, and the nutritive molecules 
which maintained the integrity of its tisyies, in doing which it performed 
glandular functions. On the rise of an inflammation, the latter of these 
secretions is arrested, and continues suspended to the end ; but the former 
as certainly increases, and this increase, the first effect of the hyperemia, 
immediately adds to the tumefaction, which at first depends upon the con- 
gestion only. As long as the inflammation continues below a certain unde- 
finable degree, nothing but simple serum is effused ; rising above that grade 
of intensity, a portion, deserting the red corpuscles, flows off with the serous 
element in the form of a peculiar secretion — coagulating lymph. The 
serum may be reabsorbed, but the fibrine coagulates and remains, in a 
state of error loci. 

The quantity thus extravasated is such as to suggest that hyperinosis of 
the general mass of blood which we have already reviewed as a pathological 
fact. But as the blood in the depths of the inflamed part is not changed, 
we are at liberty to assume that the production of fibrine from some other 
element of that fluid goes on more efficiently there than in the other organs 
which are only affected with fever. The part, in fact, is now in a state of 
orgasm, and may elaborate its peculiar secretion in corresponding quan- 
tities. Thus far, all that has passed from the vessels, or been developed in 
them, is analogous to the existing fluid and solid elements of the body, and 
need not be eliminated from it; but should the hyperemia and the orgasm 
continue unabated, a second morbid product, pus, is formed from the same 



INTERIOR VALLEY OF NORTH AMERICA. 685 

materials with the first. But although elaborated from the same elements, 
that fluid is not analogous to any existing fluid of the system, but hetero- 
logous, and requires to be evacuated. Its production has relieved the organ 
from its hyperaemia, and the suffering consequent on that condition, but in 
doing so has created the necessity for an external discharge. Should this 
not take place, it may be absorbed, if the quantity be not great, and elimi- 
nated with the excretions, or deposited in the cellular tissue of some 
distant organ, constituting the cold abscess of the surgeons. 

Now, let us look at the series of actions and events through which we 
have passed, with a view to antecedence and subsequence, or cause and 
effect. We find, then, that a casus inflammationis has directly or indi- 
rectly raised in a part an irritation or morbid excitement; this has retained, 
drawn into, or otherwise accumulated in its small vessels, an extraordinary 
quantity of arterial blood; this hyperaemia, the effect of the primary irrita- 
tion, becomes, reactively, a cause of aggravation to the morbid condition of 
the solids which produced it; in this state of things, a new effect, the secre- 
tion of serum, and then of lymph, ensues, which may or may not pass on 
to that which is purulent. Thus, the products of the inflammation are 
mainly the effect of the hyperemia; but that, without the co-operation of 
the irritated solids, would give us only the serous effusion consequent on 
passive congestion. 

We may now see the difference between the inflamed organ, and another 
in the state of fever. Increase of secretion, nature's remedy for capillary 
congestion, and according to the laws of the living system, a necessary effect 
of such congestion, cannot take place without it. But there cannot be uni- 
versal capillary congestion, and therefore there cannot be the third and last 
class of phenomena, the products of inflammation. The other organs may 
have their vital properties degraded, their nutrition suspended, and their 
functions perverted or arrested, without pouring out morbid secretions. Yet 
it may and often does happen that some organ becomes the seat of a new 
hyperaemia, and whenever this occurs, its legitimate effects, the morbid secre- 
tions of which we have so often spoken, show themselves. 

An acute phlegmasia cannot endure very long, for reasons given in the 
last chapter ; but reduced in violence, yet not subdued, it may assume a 
chronic form, and in that grade of excitement run on for an indefinite time. 
The lingering fever, not well sustained by the low and feeble inflammation, 
may at length cease altogether and the local affection alone remain, as it 
only might have existed in the beginning. But in other cases, when it is 
cured, the fever ceases. 

The secretion of pus generally carries off or reduces the inflammation to 
such a point, as that the fever ceases ; but if a large abscess remain unopened 
or its contents being discharged, an extensive surface secreting pus should 
remain, a new type of fever, the hectic, sets in, the study of which will 
come up hereafter. 



686 THE PRINCIPAL DISEASES OP THE 

SECTION II. 

ANATOMICAL LESIONS. 

"What microscopic changes of structure may exist in an organ when it is 
brought into that state which causes it to accumulate blood, has not, I sup- 
pose, been yet revealed. A priori, I see no great reason for admitting the 
existence of any; seeing that the tissues were built up and endowed with 
certain properties by some formative force, which, preceding their origin 
and residing in the unorganized fluids, could not be the effect of organiza- 
tion. The properties thus bestowed upon them, are what give efficacy to 
external agents in changing this mode of action. These aptitudes of orga- 
nized and living matter, must, I apprehend, be received as ultimate facts, 
beneath which lies a region of transcendentalism. It would also, I think, 
be gratuitous and illogical to say that inflammation begins by an alteration 
of minute structure, seeing that its causes are not so applied as by its mate- 
rial presence to reach that structure in its minuteness, and give us, as the 
starting point, an anatomical derangement. I prefer, therefore (excluding 
the effects of mechanical violence), to speak of the first link as a physiologi- 
cal lesion, the result of the influence of causes exerting their power on the 
susceptibilities of the part. 

But the next link of the chain does present an anatomical lesion as far as 
a change in the relative quantity of solids and fluids can constitute such a 
lesion. The part contains more blood than before, and some of it extrava- 
sated upon the surface or into the interstices of the organ ; this condition, 
however, being an effect of a previous morbid state, does not give an organic 
origin to the inflammation, even if it could with greater propriety than it 
can be denominated a derangement of structure. With the secretion or 
extravasation of the albuminous elements of the blood into masses of the 
organ, and the adhesion of the white corpuscles or the coagulating fibrine 
to the inner surface of the small vessels, the true anatomical lesions have 
their beginning. In these pathological events, taken in connection with that 
hyperinosis which keeps up the supply of the plastic material, we find the 
parentage of that richest and most diversified, yet (referring to the mission 
of our profession) melancholy exhibition of morbid specimens which our 
cabinets display. 

We are indebted to modern pathological anatomists for the establishment 
of the great and comprehensive fact, that the fibrinous element of the blood 
increased, separated in general from the colored corpuscles, but dissolved 
in the serum, can be so diffused and so carry itself among the structures, as 
to produce the derangements, often continuing through a long life, of which 
I have spoken. 

But we must return to the condition in which the inflamed organ is found 
immediately after death from one of the acute phlegmasia. Its tissues are 



INTERIOR VALLEY OF NORTH AMERICA. 687 

softened and tender; its vessels are engorged with florid blood, which, from 
the presence of so much adhering fibrine, can be but partially washed or 
pressed out; a portion of it, moreover, is extravasated, giving punctate or 
larger ecchymoses. At the same time the ramiform aspect of the vascular 
tissue is greatly obscured ; the areolar tissue is increased in gravity by 
infiltrations of fibrine, and whatever cells the organ may have had are 
filled with the same material. On the mucous surfaces it is but seldom 
found, but it overspreads the serous or coagulated floats in their cavities. 
If suppuration have taken place, it is still present, and often coagulates 
around the pus so as to prevent its diffusion. Seen at a more advanced 
period, it is found to have become organized, participates in the circula- 
tion of the blood, adheres to the tissues, and often agglutinates the organs 
together. Continuing to contract, it loses its proper vessels, acquires 
greater firmness, obliterates minute cells and the areolar tissue, and increases 
the density of the organ, while it effaces the original structure. If thrown 
upon the surface, its ready union and continued contraction give external 
compression with change of form ; and thus continuing to act within or with- 
out, sometimes in both modes, it effects those transformations and vascular 
obliterations, which not only annihilate the functions of a part, but by in- 
terrupting its nutrition, at last lead to its softening and gradual absorption. 

In opposition to all these injuries, however, we may place its inherent 
plasticity, its capacity for forming itself into tissues analogous to those of 
the whole body, and its indispensable agency in the reunion of divided parts, 
and the reproduction of those which have been lost by external violence, 
suppuration, sloughing, or gangrene. 

Of suppuration as a structural lesion it will be proper to say something 
more. All the organs and tissues are not equally prone to suppuration 
when inflamed. It chiefly occurs in the parenchymatous, the cellular, and 
the mucous. Hence, abscesses of the liver, kidney, spleen, brain, the ton- 
sils, the parotid glands, and the lungs when tubercular, are not uncommon 
events. Those of the subcutaneous and intermuscular tissue are, however, 
more frequent. The mucous membranes may secrete pus without a visible 
lesion of structure, but those of the digestive canal are especially apt to be 
affected with ulceration ; a condition which quite as readily establishes itself 
in skin, and the sero-mucous covering of the eye. 

When the hypersemia of an inflamed organ is very great, and the vis a tergo 
of the heart is either very powerful, or from feebleness of constitution very 
small, the turgid vessels do not assume that kind of secretory action which 
relieves them ; but fail in energy, and the death of the affected part ensues. 
If the organ in which this occurs should be essential to life, the death of 
the rest is of course inevitable ; if otherwise, inflammation with secretion 
of pus is set up around the gangrened part, and may lead to its separation, 
when restoration more or less perfect takes place through the medium of 
granulation; the lost tissues being reproduced out of coagulating lymph. 



688 THE PRINCIPAL DISEASES OP THE 

Of all the tissues, the skin and subjacent cellular substance and the mucous 
membranes, are most liable to this serious result of inflammation. 



CHAPTER V. 

INDICATIONS AND MEANS OF CURE. 

The phlegm asiae or phlogistic fevers, constitute an extensive and the 
only group of diseases, which, in their pathology, resemble each other so 
closely, that the same therapeutic principles apply equally to the whole. 
The metJwdus medendi suggested by these principles is called the antiphlo- 
gistic treatment, of which we must now make a short but comprehensive 
survey. 

In coming up to this study, we must recollect that every phlogistic fever 
presents a high tone of excitement, or an increase of vital energy in the 
heart and arteries, a state of hyperinosis of the blood, and an active hyper- 
emia of one or more of the organs or tissues. That this local hyperemia 
sympathetically excites the heart and increases the energy of its contrac- 
tions, which in turn, by augmenting the momentum or vis a tergo of the 
circulation, injects the inflamed organ with a force that aggravates the in- 
flammation. That in connection with this remarkable disturbance of the 
function of circulation, there is a marked perturbation of the associate func- 
tion of innervation, leading to the manifestation of acute pain and tender- 
ness in the inflamed part ; pains and aches in various other parts not affected 
with hyperemia; and increased but morbid sensibility in the nerves of 
special sensation, including those which take cognizance of changes of 
temperature. 

Such, in a condensed view, being the condition of the system, the follow- 
ing indications of cure present themselves : 1. To subdue or reduce the 
general and the local excitements. 2. To alter or change the type or mode 
of morbid action. 3. To soothe excessive sensibility and excitability, that 
is, to moderate constitutional irritation. 4. To equalize the capillary circu- 
lation, and thus by revulsion to relieve the organ or organs which are in a 
state of hypersemia, either passive or active. 5. To revive the impaired 
or suspended excreto-secretions, and thus depurate the blood rendered im- 
pure by thejr suspension, not less than by the morbid diathesis of the sys- 
tem throughout the fever. 6. To restore the lost strength of the organs of 
nutritive or organic life. Let us consider these seriatim. 

I. To Reduce the Excitement. — When we look at a catalogue of the 
means, which the experience of the world has declared to be most efficacious 
in the fulfilment of this most important indication, we find that they may 
be referred to three heads. 1. Exclusion ; 2. Abstraction ; 3. Refrigeration. 



INTERIOR VALLEY OF NORTH AMERICA. 689 

1. Of Exclusion. — By withholding or excluding from the patient, certain 
agents, which in health give normal activity to the functions, we diminish 
the morbid and energetic activity which it is our object to subdue. The 
simple enumeration of them, carries conviction to the mind that their ex- 
clusion must be attended with benefit, since their application would produce 
aggravation. The principal are: — 1st. Food; 2d. Stimulating drinks; 3d. 
Caloric; 4th. Locomotion; 5th. Light and sound; 6th. Society. A rigid 
avoidance of these stimuli is sometimes sufficient to effect the reduction of 
a mild phlogistic fever ; and of course such an avoidance is indispensable 
to the successful treatment of the more acute. As a general fact the in- 
stincts of the patient are unerring in reference to the whole, but a false 
theory of fever, in former times, suggested the avoidance of cool, rather than 
of hot air, and established a popular prejudice, the hereditary propagation 
of which has not yet been ftilly arrested. 

2. Abstraction. — The most efficient means of lowering the excitement in 
the phlogistic fevers belong to this head ; and being, in their nature, of a 
more positive and powerful kind, they cannot, like the negative measures 
referred to in the last head, be dismissed with a bare enumeration. Let us 
consider them in the order of their efficiency. 

a. Bloodletting. — The first effects of the loss of blood are found in the 
organs of circulation, on which that fluid acts in two ways ; first, by the 
stimulus of distension; second, by its exciting qualities, physiologically 
adapted to the contractility of the heart. The next effect is on the brain, 
which, from the diminished volume of the blood and the reduced power of 
the heart, is less violently injected, and has the momentum of its circula- 
tion diminished. In this condition its reactive influence on. the heart and 
vascular system is moderated, tending still further to bring down the energy 
of the circulatory apparatus. Effects of a similar kind are probably pro- 
duced in and through the spinal cord. Intimately related to these are the 
effects of the loss of blood on the arterial trunks and capillaries, which, if 
it be suddenly and copiously drawn, do not contract pari passu, and, there- 
fore, lose the stimulus of distension, as well as that imparted by the specific 
properties of the blood. This reduction of the force of the heart diminishes 
the vis a tergo of the blood going to the inflamed organ, a source of relief; 
while the venous depletion favors the escape of blood from it, and thus pro- 
motes the resolution of the hyperemia, the reactive influence of the inflamed 
organ on the heart, through the nervous system, being at the same time 
abated. These results, however, when the fever is violent, are not obtained 
by a single venesection, and some cases demand several. Yet it has been 
discovered that the fibrine increases in the midst of these repeated bleedings, 
and some physicians, in opposition to an experience that seems entitled to 
confidence, have almost doubted their propriety. But we must remember 
that the hyperinosis is not the cause, but the effect of the inflammation, 
and that it must, of necessity, continue till that pathological condition is 
vol. ii. 44 



690 THE PRINCIPAL DISEASES OF THE 

subdued • still further, we must recollect that repeated bleedings rapidly 
reduce the quantity of red corpuscles, which are, perhaps, the stimulating, 
while fibrine is the nutrient element of the blood. In short, it may be 
that the directly enfeebling effects of bloodletting are mainly referable to 
the loss of the corpuscles. To all this, I may add that bloodletting gives 
effect to other measures, and is, therefore, indirectly beneficial. 

Acting in these various modes, we need not be surprised that venesection, 
instinctively resorted to even by savages, has, at all times, been regarded 
as an indispensable remedy in the phlogistic fevers. But, to be successful, it 
must be employed in the manner and degree that will produce the effects 
which have been enumerated. 

Local bleeding must come after, not before, general bleeding. To be 
useful, it must either be employed before the heart has come into full sym- 
pathy with the inflamed organ, or after its force* has been reduced by vene- 
section. Local bleeding diminishes the turgescence of the capillaries of the 
inflamed part, which abates the activity of the lymphatic secretion set up 
in them, and favors the vascular contraction by which they send forward 
the retained blood. Thus, by relieving the organ, its reactive, irritating 
influence on the heart is abated, when, of course, that organ acts with less 
violence, an effect which has been erroneously ascribed to the small diminu- 
tion thus produced in the general mass of blood. 

In addition to all the direct benefits which bloodletting confers, we must 
take into account its modifying influence on the action of other remedies. 
Thus, when the vessels are full, and the power of the heart great, the 
means appropriate to fulfil other indications will often fail to produce their 
wonted effects, and may even do harm before the employment of that 
remedy. This is true of emetics, cathartics, sudorifics, antiphlogistics, alte- 
rants, revulsives, and narcotics, none of which can be successfully employed, 
while the arterial excitement is above a certain point; but which operate 
kindly after the adequate use of the lancet. 

b. Purging, only considered here as a means of fulfilling the first indica- 
tion, should be viewed under two aspects, and employed for immediate pur- 
poses. In the first place, it removes from the stomach and bowels the 
undigested and feculent accumulations, which, retained there after the fever 
commences, aggravate it. For this object, saline, and other gentle aperients, 
or even large emollient injections, if the stomach be irritable, are generally 
sufficient, without the risk of irritating the bowels. In some cases, this 
simple expulsion of the existing contents of the primse vise, in connection 
with the exclusions which have been enumerated under the preceding head, 
will arrest the fever. But it frequently happens, that the arterial system is 
so highly excited that the aperient acts but imperfectly, or not at all, till 
the lancet is employed. Secondly. Purging may be made to assist in de- 
pleting from the bloodvessels; but to do this, it must be excited by articles 
which promote secretion from the liver and mucous membrane. Given 



INTERIOR VALLEY OF NORTH AMERICA. 691 

early in the fever, however, they often fail of the desired effect, and may 
even invite the inflammation into the mucous membrane ; for those of a 
drastic and hydragogue character are required. In all cases of high phlogistic 
excitement, the lancet, for the reasons already given, should either precede 
or immediately follow on their exhibition. This rule is often violated by 
physicians who are adverse to bleeding, or lack firmness in regard to the 
fears or prejudices of patients; and thus in false reliance on purging, as a 
means of lowering the tone of vascular excitement, the disease goes on to a 
fatal termination. 

c. Refrigerants. — It cannot, I think, be doubted, that in whatever man- 
ner — whether from external application or internal development — the free 
caloric of the body is raised above the normal standard, it increases the 
morbid excitement. The abstraction or absorption, therefore, of the heat, 
liberated from a latent to a free condition, in the phlogistic fevers, must be 
regarded as an important therapeutic measure. This may be accomplished, 
1st. By cool air in a free current: 2d. By the application of cold, cool, or 
tepid water to the surface of the body, when the seat of the inflammation 
does not forbid it, and also to the inflamed part when external; which ap- 
plications must be made in such manner as not to produce reaction, that is, 
a very low temperature should be avoided. 3d. By copious internal dilu- 
tion with cold or tepid water. The lodgment in the stomach of a large 
quantity of that liquid, having a temperature but a little lower than that of 
the body, cannot fail to reduce its heat; but the effect is greatly augmented 
by the passage of the fluid into the portal veins, and thence into the general 
circulation. In thus traversing the body, it absorbs caloric, dilutes the 
superabundant fibrine, and may be supposed to diminish its tendency to 
coagulation in the capillaries, which would lay the foundations of secondary 
inflammations; still farther, by acting on the kidneys, it carries out the 
irritating elements of the urine, or, on the skin and bronchial membrane, it 
promotes a diaphoresis, which, evaporating, tends further to abate the 
morbid heat of the system. 

Several refrigerants may be beneficially added to the water thus adminis- 
tered. First, the vegetable acids, at all times acceptable to the patient, 
and in all countries found to exercise an effect on the heat of the body; 
second, certain neutral salts, such as the nitrate of potash, bicarbonate of 
potash, and the tartrate and bicarbonate of soda; third, demulcents, such as 
gum Arabic and elm bark, which, whether received internally, or applied to 
an inflamed part, seem to have the power of moderating temperature.* 

All the measures which have been proposed concur in one effect, reduc- 
tion of, not change, in the force of the morbid excitement. If we inquire 
for the therapeutic principle which unites the whole into a single group, 

* For further remarks on this subject see vol. i. p. 806. 



692 THE PRINCIPAL DISEASES OF THE 

we do not find it in a diminution of the excitability of the system, but in 
the reduction of those agents denominated stimuli, including the blood, 
without which the vital susceptibilities can neither develop nor maintain in 
activity the functions of the organism. The effect produced is, indeed, the 
direct debility of Brown. Under this treatment, the inflammation is often 
resolved and the fever terminated ; yet it so frequently fails, that recourse 
must be had to the means of fulfilling other indications, and this brings us 
to our second general head.* 

II. To Change the Mode of Action. — Without insisting strenuously 
on Mr. Hunter's incompatibility of action in the treatment of disease, we 
may bring under this head several agents which deserve the name of anti- 
phlogistic alterants. Their impression on the system supersedes, more or 
less perfectly, the inflammatory action, and when the former dies away the 
latter does not revive. If their effects did not subside spontaneously, they 
would but substitute one type of morbid action for another. Experience 
proves that it is a pre-requisite to their successful administration, that the 
phlogistic excitement should not be very high ; and thus their effects are 
generally much better after than without bloodletting. The neglect of this 
maxim, may indeed not merely nullify their benefits, but render them inju- 
rious. Yet some of them exert a sedative not less than alterant influence, 
and therefore assist in fulfilling the preceding indication, while they are ac- 
complishing the one now under consideration. Even these, however, act 
more kindly, both as sedatives and alterants, after venesection. Another 
view which should be taken is that some direct their action more on one 
organ, others on another, which suggests a choice, that will if possible carry 
an alterant influence into the seat of the inflammation. Keeping these 
maxims in mind, let us proceed to consider the principal articles which 
belong to this head. 

1. Tartarized Antimony. — This is one of our most potent antiphlogistic 
alterants ; while it changes the type of action from the inflammatory to the 
antimonial it directly lowers the excitement. Thus it fulfils two indications. 
Its sedative, or rather its enfeebling influence on the heart and arteries, renders 
it a tolerable substitute for the lancet in the milder phlegmasioe, and hence 
it may be given when the grade of inflammatory excitement precludes almost 
every other alterant. Still when the disease is intense it may fail in its 
characteristic effects, and even excite gastritis if blood be not abstracted ; 
after which it may render repeated venesections unnecessary. It is impro- 

* The method pursued by the Broussais school, for the cure of phlegmasia, including, in their estima- 
tion, all fevers, consisted in little else than what we have just enumerated. Thus it was still more 
defective than their pathology was erroneous; for admitting the latter, the remedies they proposed were 
by no means the whole which should he employed. The founder of the sect was a man of high talents ; 
hut his experience was subordinated to his genius, and his popularity was destroyed by his therapeu- 
tics : too active where, as often happened, no inflammation really existed, and too weak and simple 
when it was acute. ' ' - > ; ; 



INTERIOR VALLEY OF NORTH AMERICA. 693 

per only when the stomach and duodenum are inflamed, or in cases of peri- 
tonitis and hepatitis, which generate sympathetic gastric irritability. It 
acts better in mucous than serous inflammation, because it fulfils our fifth 
indication in promoting secretion, while in serous inflammation it is impor- 
tant to arrest that function. It is well adapted to inflammation of the skin 
and subjacent tissues, the white fibrous structures, the mucous membrane of 
the ileum and colon, the tonsils and pharynx, the larynx, the bronchial 
tubes, and the air cells and areolar tissue of the lungs, upon which it may 
be said most constantly to exert its power. In the phlegmasia of the heart 
and brain it has seemed to me less beneficial, but is not contraindicated. It 
co-operates well with calomel, opium, diuretics, and sudorifics, and thus on 
the whole is, I think, the most important antiphlogistic of our materia 
medica. 

2. Calomel. — The alterant effects of this antiphlogistic are known to all 
the world. It irritates the stomach less than tartar emetic, in general not 
at all, and often quiets that organ when other means have failed. Hence it 
is well adapted to gastro-enteritis and inflammation of the liver, over 
which it exerts an alterative control, quite equal to that of tartar over the 
lungs. In the mucous inflammation of the ileum, coecum and colon, it pos- 
sesses no power beyond, if equal to, that of tartar. In the phlegmasia of 
the serous membranes we see its greatest triumphs. It has been said to 
effect these by diminishing the hyperinosis of the blood, but it produces 
that result by moderating the inflammation. Having what may almost be 
called a specific influence on the serous tissue it is equally applicable to peri- 
tonitis, pleurisy, pericarditis, endocarditis, arachnitis, iritis, and tracheitis, 
when the very simple mucous membrane of the trachea is throwing out a 
quasi coagulating lymph. On the secretions of the skin, lungs, and kidneys 
it exerts much less influence than tartarized antimony, on those of the liver 
and salivary glands more. Its reducent power over the high excitement of 
the brain and heart, is less than that of the medicine last named ; but the 
constitutional diathesis (morbus mercurialis) which it sets up is more 
strongly characterized and enduring, and to this we may ascribe its greatest 
benefits. As a simple antiphlogistic alterant, its power is indeed very great, 
and so genial is its impress in simple acute inflammation of the serous and 
fibrous tissues, that it may be safely administered through their violent 
stages, in doses which would prove highly injurious in many other types of 
constitutional disease. Hence deleterious results from the abuse of this 
mediciue are seldom found in the treatment of the acute phlegmasia. 

3. Digitalis, Squill, and Colchicum. — Each of these medicines acts as 
an alterant in the phlegmasia, being able to impress the system in its own 
manner : which is one that tends to supersede the pre-existing morbid excite- 
ment. But their good effects do not arise wholly from this power, for (if 
bloodletting have preceded their use) they abate the action and diminish the 



694 THE PRINCIPAL DISEASES OF THE 

force of the heart, and thus fulfil our first indication, but in a different way 
from the means enumerated under that head, which consisted of the exclu- 
sion and abstraction of stimuli, while these agents diminish or obtund 
the vital properties of contractility and sensibility. Hence they contribute 
to the accomplishment of our third indication, allaying constitutional irrita- 
tion. While they decidedly affect the innervation and circulation, they 
affect but few of the secretions ; yet colchicum increases that of the bowels, 
and squill those of the lungs and kidneys. Digitalis and indeed the whole 
excite the absorbent system, and thus promote the early absorption of coagu- 
lating lymph. Considered in reference to the inflamed organ, digitalis is 
best adapted to the heart and lungs, especially the former, the squill to the 
bronchial membrane, and colchicum to the fibrous tissues. The squill acts 
harmoniously with calomel; digitalis with tartarized antimony, and colchi- 
cum with opium. There are other antiphlogistic alterants, but in these we 
have the types of the whole ; and as the remainder are in general less re- 
liable, I shall pass them by, and proceed to our next indication. 

III. To Allay Irritability. — To reduce and change the morbid ex- 
citement are the great curative objects in the acute phlegmasia ; but another 
less important and contingent end must be accomplished, both for the safety 
and the comfort of the patient. The bloodletting which cannot always be 
accurately adjusted to the demands of the case, and the other exclusions 
and abstractions of stimuli recommended under our first head, frequently 
develop a state of constitutional irritation, which, unattended to, prolongs 
the sufferings of the patient, and may sometimes prove fatal. The diagnosis 
of this condition, so well recognized by Sydenham, is often difficult, even 
to the experienced physician, who may imagine from the increased impetus 
of the heart, and the restlessness and complainings of the patient, that the 
original disease is on the increase, and thus redouble his efforts in the anti- 
phlogistic treatment. A feeling of alarm and a sense of thoracic weight or 
constriction, coldness of the feet, increase of urine, and a dead-leaf hue, or 
the fur on the tongue, will, in general, characterize this incipient neurosis. 
Additional diagnostic aid may, however, be had from noticing the tempera- 
ment of the patient, the lymphatic being that which most favors its deve- 
lopment. Of all the phlegmasia those of the brain and liver are, I think, 
most apt to be accompanied by it. Opium (including its preparations), is 
the great remedy for this morbid innervation. It can be combined with the 
alterants which it may still be proper to administer, for the inflammation is 
not always subdued when this new type of action arises, or it may be given 
alone or with diaphoretics, when it aids in fulfilling the indication of restor- 
ing the suspended secretions. Carbonate of ammonia, camphor, and assafce- 
tida, are also beneficial, but their effects are less certain and more transient 
than those of opium. When the physician feels assured that inflammation 
is reduced, alcoholic stimulants and food will be proper, and may even ren- 
der opium, except at night, unnecessary. 



INTERIOR VALLEY OF NORTH AMERICA. 695 

Another form of nervous irritation demands opium even in the earlier 
stages of the inflammation. I refer to that of the heart, the stomach, and 
bowels. When the first is inflamed, its violent convulsive action is but 
little moderated by copious depletion, and opium is required to reduce its 
irritability. It may be combined with calomel, digitalis, colchicum, or 
whatever alterant may be in use. In acute gastritis or peritonitis intesti- 
nalis, the disordered peristaltic function often demands opium, even while 
the inflammation is yet severe. The vomiting in many cases cannot be 
moderated without it, and while no appropriate alterant can be retained, 
the violent muscular contractions are torturing the inflamed mucous mem- 
brane. In the bowels, various forms of spasmodic contraction may do harm 
in the same way, and demand the administration of the same remedy, which 
is not contraindicated by the constipation of the patient, but rather the 
reverse, for cathartics will act more certainly and kindly after the spas- 
modic action is abated than before. 

I cannot leave this head without expressing, though not without hesita- 
tion, the opinion, that the full power of opium in the treatment of the simple 
phlegniasise, has not been developed. That medicine is an alterant not less 
than a narcotic. It produces its peculiar morbid diathesis, both acute and 
Chronic. A large part of the alterative effect is found in that reduction of 
the contractility and sensibility which constitutes the object of the indica- 
tion we are now studying. Now what is more likely to eradicate both in- 
flammation and its accompanying fever, than diminishing those vital sus- 
ceptibilities, without an exaltation or perversion of which no inflammation 
can arise ? To administer opium before bloodletting, when the action of 
the heart is powerful, is to increase the excitement, but immediately after 
free venesection its effects are so entirely different, that I have often ques- 
tioned with myself whether the physician who might be deprived of other 
agencies, could not by these alone subdue all the phlegmasia except those 
of the brain ? 

IY. To Equalize the Excitement. — Under this head fall all counter- 
irritants and other revulsives. Their successful employment calls for two 
precautions : first, to reduce the general excitement before resorting to 
them, especially counter-irritants; second, always to make the revulsion to 
an organ or surface of less importance in the economy than the one inflamed. 
Inattention to the first of these rules has inflicted on patients an immense 
amount of suffering without any benefits. While the bloodvessels are full, 
the heart strong in its action, and the nervous system highly excited, to say 
nothing of the state of the inflamed part, revulsion cannot be effected. A 
new inflammation may be induced, but the system can and does sustain 
both, and that the more certainly because the second acts as a stimulant to 
it. There is an apparent exception, but it confirms the rule. In ihs form- 
ing stage of the inflammation and before the constitutional excitement has 
begun or acquired much intensity, a large counter-irritant is sometimes fol- 



696 THE PRINCIPAL DISEASES OF THE 

lowed by an arrest of the local disease ; but after its full development the 
result is entirely different. Counter-irritants appear to relieve inflamma- 
tion by inviting nervous force and blood into a new part with which the 
affected stands in anatomical or physiological relation, when the energies of 
innervation and circulation are so reduced that they cannot well supply two 
demands, and, therefore, on the rise, under a new cause, of the second 
capillary orgasm, the first dies away. But without attaching any importance 
to this speculation, we may say that the practice which it demands is that 
which the ablest physicians have found most successful. I lately heard a 
paper read,* in which the author argued that it was by drawing off coagu- 
lating lymph from the neighborhood of the inflamed part that blisters were 
beneficial. That the vesicles in this state of the system often show the 
presence of the fibrinous element of the blood is well known ; but this is 
sufficiently explained by the hyperinosis of the blood, wbich I regard as the 
effect and not the cause of the inflammation. 

Two classes of patients do not bear the liberal and protracted application 
of blisters, they are persons, especially women, of a nervo-lymphatic tempe- 
rament, and small children with delicate skins. In the former, the blistered 
surface sometimes becomes the seat of an intolerable nervous irritation ; and, 
therefore, rubefacients more transient in their effects are generally to be 
preferred. In the latter, an unfavorable irritation is in some instances car- 
ried through the nervous system, and the blistered surface now and then 
becomes gangrenous. The blister should thorefore be removed on the first 
appearance of vesication, and an emollient poultice applied ; a practice 
which has become much commoner in latter than it was in former years. 

Revulsion may be effected without counter-irritation, and in many cases 
to a much greater extent. Thus a long-continued and rather hot foot-bath 
will make greater revulsion from the head than a pair of blisters above the 
ankles, or rubefacients to the soles, though it will be less permanent; and 
moderately stimulating emollient poultices or fomentations over the abdo- 
men in peritonitis, will often accomplish as much as blisters, while they 
contribute to allay the spasmodic action within, and thus aid in the fulfil- 
ment of another indication. Purging is another and powerful means of 
revulsion. In this cause it is increased secretory action which invites blood 
to the part and expends nervous force. A great portion of the benefit of 
purging in the phlegmasia is thus obtained. Thus, in gastritis, when the 
bowels can be brought to secrete and excrete freely, the stomach becomes 
more composed; and the condition is beneficial in the same manner in peri- 
tonitis, hepatitis, and splenitis, especially when not connected with autumnal 
fever. In these cases the blood is not accumulated in the intestinal mem- 
brane, but supplies the material for increased secretion ; and the benefits of 
topical depletion are obtained with those of revulsion. To this end, the 
hydrogogue cathartics are best adapted. By a parity of reasoning we per- 

* By Dr. Thomas Wood, before the Med. Chir. Society of Cincinnati. 



INTERIOR VALLEY OP NORTH AMERICA. 697 

ceive how cbolagogues relieve the liver and all the portal viscera, and that 
they should not be neglected. This method of revulsion is not without its 
benefits in the phlegmasia of the heart, but in those of the lungs it has not 
been found expedient, the reason of which seems to be that the natural cure 
of pulmonary inflammation is by expectoration; and that as two great 
secreting organs cannot well be in a state of excited function at the same 
time, that of the lungs is retarded or suspended by that of the bowels. If, 
however, purgative revulsion is useless or injurious, when the pulmonary 
organs are the seat of inflammation, it is very different when the brain and 
spinal cord are affected. In every variety of acute cerebral inflammation, 
the revulsion effected by free purgation is of inestimable value. The heavi- 
ness, headache, and sometimes vertigo attendant, on costiveness, with the 
immediate relief produced by free alvine evacuation ) and the extreme 
though transient debility which occasionally follows on a sudden and 
copious discharge from the bowels, instruct us on the physiological relation 
between those organs and the brain ; and might have been sufficient to 
suggest the remedy which an ample experience has so decidedly approved. 
Lastly, purging makes revulsion from the joints and fibrous tissues of the 
limbs and also from the skin and areolar tissue beneath. This marked in- 
troversion of the blood and nervous force, which every physician has so 
often witnessed, abates morbid function in the organs which have been 
named, and brings out beneficial results in the inflammations consequent on 
external violence, in rheumatism, in phlegmon, and in scarlatina, and cer- 
tain cases of erysipelas. 

In conclusion, I may speak of revulsion the very opposite of the last. 
Sudorifics impart a centrifugal direction to the capillary circulation, and the 
nervous energy which is expended in the functions of which they are the 
incitors. When the vessels of the skin are made to receive a large quantity 
of blood, the viscera, of course, circulate less, and the remains of inflam- 
matory hyperemia may be carried off. In this case, the revulsion is made 
from more to less vital parts, and can never do mischief, though the efforts 
to effect it when the excitement of the system is too high, may not merely 
fail, but prove injurious. The measures requisite to this revulsion deserve 
a paragraph. They are, in general, most efficacious immediately after vene- 
section, or purging, the latter having ceased. They should be brought to 
bear on the system at night, and a certain degree of narcotism greatly 
favors the desired result. 

Again, posture is in many cases an efficient revulsive, giving to that word 
its most extensive signification. Thus, if the inflammation be in the brain, 
an erect position mitigates, while a horizontal aggravates it ; if in the hand 
or foot, hanging down increases the hyperemia and pain ; while elevation 
into an unnatural position in reference to the heart, diminishes the momen- 
tum of the circulation, and works out the effect of powerful revulsion. 

V. To Promote or Restore the Suspended or Depraved Secre- 



698 THE PRINCIPAL DISEASES OF THE 

tions. — As we all know, the secretions do not remain normal in the phleg- 
masia. Seldom increased, they are generally diminished, and always de- 
graded in character. This state of the secretory functions, the effect and 
not the cause of the fever and the inflammation, generally ceases when they 
are arrested, and cannot, to any great extent, be corrected while they con- 
tinue, especially the fever. But we may sometimes re-establish a secretion 
during the phlogistic condition of the system, and make it a physiological 
remedy. Facts, bearing on this point, have been mentioned under some of 
the preceding heads. Thus, increased secretion co-operates with bloodlet- 
ting in the work of general, with cupping in that of local depletion ; while 
the augmented supplies of blood and nervous influence extended to an organ 
in a state of excited function, makes derivation or revulsion from that which 
is inflamed. The means, appropriate to the indication we are now consider- 
ing, have likewise been glanced at in several places. Thus, tartarized anti- 
mony, ipecac, squill, lobelia inflata, polygala senega, and the sanguinaria 
canadensis, with diluents, mucilages, and gentle opiates, increase the secre- 
tion from the bronchial membrane, and carry off pulmonary congestion. 
Minute doses of the first two medicines, infusions of eupatorium perfora- 
tum, sage, orange leaves, and other simple diaphoretics, with sulphate of 
morphine, or Dover's powder, aided with tepid foot-bathing, act also on the 
pulmonary mucous membrane, but are here presented as sudorifics; and 
when they succeed, it is with an attendant, outward direction of the cur- 
rents of the circulation, whereby internal hyperemias, and, above all, those 
of the lungs, are diminished. The urinary secretion — antagonistic to the 
perspiratory — may be augmented by the cool operative diuretics, nitrate and 
bitartrate of potash being the best; by squill, combined with nitre, and by 
the spirit of nitrous ether, taken in cold diuretic infusions, with an exclu- 
sion of whatever might determine their action upon the skin. The diuresis, 
thus excited, cannot be said, on anatomical grounds, to make revulsion from 
any particular organ, but it rids the blood of those elements which it is the 
function of the kidneys to eliminate from the system; and by exciting the 
absorbents, promotes the absorption while it is yet fluid, of the coagulating 
lymph, which is thrown out by the inflamed vessels. When the inflammation 
is seated in the lungs, and life is threatened by the impaired decarbonization of 
the blood, an increased secretion of urine, by carrying off carbon, the largest 
element of the extractive matters of that fluid, may be found beneficial.* 
Whatever value may be granted to this operation, experience has shown that 
in pulmonary inflammation the administration of certain diuretics is beneficial, 
yet as they are also expectorants, the greater part of their benefit may arise 
from their action on the lungs. When the inflammation has its seat in the 
brain, it is also peculiarly proper to augment the secretion of the kidneys, 
and prevent accumulations of urea and uric acid in the blood, which obser- 
vation has taught us act perniciously on the cerebral organ. In speaking 

* See Simon's Cbem. of Man, Am. Ed. p. 423, in a note. 



INTERIOR VALLEY OF NORTH AMERICA. 699 

of hydrogogue and cbolagogue cathartics as a means of revulsion and of de- 
pletion from the abdouiinial organs, but little was left for introduction 
here. A greatly reduced activity of the portal secretions is a common pa- 
thological condition in the phlegmasiae, and the necessity of re-exciting them 
while the fever is still unreduced, is often urgent. The liquor intestinalis 
is frequently secreted when the bile is not, rarely the reverse. It has not 
been found beneficial to promote the former and neglect the latter; but 
when the liver acts freely, the mucous membrane may be quickened into 
increased secretion with good effect. The most efficient agents for fulfilling 
these indications, are calomel (in preference to the blue pill), tartarized an- 
timony in small doses, sulphate of magnesia in combination with the last, 
or dissolved in senna-infusion, elaterium with bitartrate of potash, and lastly 
the compound powder of jalap. 

In these various attempts to quicken the inactive or suspended organs of 
secretion, we must never forget that they should not be entered upon, till 
the arterial excitement has been moderated by bloodletting and other direct 
debilitants. "When the fever has been subdued, it sometimes happens that 
some great secretory function — that of the skin, the lungs, kidneys, liver, 
or bowels, will remain comparatively inactive. In such a case the convales- 
cence will be slow. This sometimes depends on chronic inflammation, at 
other times on simple torpidity • and the means of restoration must vary ac- 
cordingly. Of the whole, the functions of the skin and liver are oftenest 
found in this condition, from which they are best relieved by stimulating 
diaphoretics and cholagogues. And this brings us, naturally, to our last 
general indication of cure. 

VI. TO REPAIR THE WASTE AND RESTORE THE STRENGTH OF THE TIS- 
SUES. — With the resolution of the inflammation and the cessation of the 
fever, the abnormal production of fibrine no doubt ceases, but the last bleed- 
ing, which might have immediately preceded these events, very often shows 
a hyperinosis or excess of fibrine. Xow, is this fibrine in that state of degra- 
dation which requires its elimination from the system? I presume not; for 
it has not been detected in the excretions of convalescence ; and up to the 
close, it is capable of becoming organized in the tissues among which it is 
secreted. We may then assume that it is immediately appropriated to the 
repair of the organism until it is brought down to the normal quantity. 
Thus, while the system is generating plastic material with which to repair 
the anatomical injury that a part may have suffered from without, it is at 
the same time providing a highly animalized food for the hungry organs, and 
as soon as the morbid action is terminated, nutrition recommences with an 
activity unknown under other circumstances. Thus, we can comprehend 
how it is that in the phlegmasia, patients often recover strength rapidly, be- 
fore they are permitted to take food, and, in general, require fewer stimu- 
lants to help them on than any other class of convalescents. This internal 
storehouse is ; however, soon exhausted; and a supply of aliment from with- 



700 THE PRINCIPAL DISEASES OF THE 

out is demanded not less by an anatomical necessity than by the remarkable 
physiological demand, which in the form of appetite, seems, as it has been 
well expressed, to reside in every organ not less than the stomach. Hence, 
the little control exerted over it by the will of the patient; while the neces- 
sity for a cautious indulgence is very obvious, for the phlegmasia leave the 
vital susceptibilities more acute than they are left by other forms of fever, 
and therefore inordinate indulgence readily awakens a phlogistic diathesis, 
more dangerous and difficult to subdue than the first. This anatomical- 
physiological demand for food abates as the organs experience reparation 
and begin to carry on their respective functions. In supplying it, we some- 
times limit our patients to amylaceous, saccharine, and other vegetable pre- 
parations ; but a better plan is to mingle with them albuminous, gelatinous, 
fibrinous, and other proteine substances, as it is chiefly they which go to restore 
the waste of the tissues. In general, food alone will suffice for the recovery 
of the patients; but those of a lymphatic temperament, of broken down 
constitutions or advanced age, may require stimulants, such as condiments, 
coffee, beer, wine, or other alcoholic drinks. If the patient, moreover, re- 
side in what is called a malarious region, or has been subject to the fevers 
of such a locality, his convalescence may be promoted by bark or quinine. 
All the organs may not convalesce at the same time, and that especially 
which was the seat of the inflammation may remain feeble and crippled. 
Thus it becomes the duty of the physician to inspect them daily, and pre- 
scribe according to their necessities. The stomach may not digest well, or 
the appetite may not return, in which case (if there be no subacute gas- 
tritis) the simple bitter, with elixir of vitriol, will be demanded ; but the 
liver is still often in fault, and will require to be stimulated to secretion 
with the blue pill and nitro-rnuriatic bath ; the bowels, moreover, may be 
sluggish, and demand the mercurial just mentioned with aloes, assafoetida, 
or galbanum, or the tincture of gentian and rhubarb. The kidneys may 
not secrete freely, and demand stimulating diuretics, such as uva ursi, oil of 
juniper, muriated tincture of iron, and the oil of turpentine. If the bron- 
chial membrane should be inactive after pulmonary inflammation, and the 
secretion of mucus deficient, that function must be promoted by stimulating 
expectorants, such as ammoniacum, compound tincture of benzoin, lobelia, 
and opium ; thus the remains of hyperemia will be carried off, and the 
absorption of serum and fibrine from the sack of the pleura promoted, while 
a freer excretion of carbon from the blood will improve the condition of the 
general economy. Finally, particular attention should be given to the skin, 
the heat of which should be maintained and equalized, while a freer dia- 
phoresis than that of health should be promoted, especially at night. To 
these ends, bathing, clothing, and atmospheric temperature, properly regu- 
lated, may often be sufficient ; but the administration at night of some sudo- 
rific draught, such as the spiritus Mindereri, or an infusion of serpentaria, 
with paregoric or Dover's powder, may, in many cases, produce the happiest 
effects. Indeed, patients during convalescence are liable to nocturnal 



INTERIOR VALLEY OF NORTH AMERICA. 701 

paroxysms of nervous irritation, which equally prevent both sleep and per- 
spiration, and are imperative calls for some preparation of opium. 

VII. I must not dismiss this branch of our subject without referring to 
two or three additional pathological conditions, which may either occasion 
a tardy convalescence, or arrest it by the formation of a new disease. 

First. I have already referred to the sinking of an acute into a chronic 
inflammation. The blaze is extinguished, but the smouldering embers 
remain, and although they may never flare up, the slow destruction of the 
tissues is not less certain. In former times, such cases were vaguely de- 
nominated chronic diseases, and we owe to the keen penetration of Broussais 
the first good account of their real character. The diagnosis of the acute 
phlegmasia is simple compared with that of the chronic, which so often seem 
like neuralgias or mere functional imperfections, and, therefore, they should 
fix. the attention of every physician. 

Second. After one of the phlogistic fevers occurring about the age of 
puberty, especially in females, the blood is left in a state of spansemia or 
deficiency in its solid elements, particularly the ferruginous. This chlorotic 
condition arrests convalescence, and, if not corrected, may generate hydropic 
effusions, or certain neurotic affections, according to the predisposition of 
different patients. The appropriate remedies are chalybeates, nourishing 
diet, and exercise in the open air. 

Third. Patients of a tubercular diathesis, either pulmonary or lymphatic, 
are in danger of having it augmented by the depletions and other enervating 
agencies to which they have been subjected, and may thus fall victims to a 
second disease, hastened into full development by the means which had 
saved their lives in a first. To prevent such a sinister result, we must have 
respect to the existence of a tuberculous diathesis while treating the acute 
phlegmasiae, and substitute, as far as possible, other curative means for 
bloodletting, and the free use of mercury, while, to effect a complete resto- 
ration, often impossible, we must, during convalescence, administer the 
bark, iodide of iron, and other tonics, while much active exercise in the 
open air, together with a generous diet, is enjoined. 

This therapeutic summary finishes our survey of the etiology, pathology, 
and treatment of the phlegmasiae or phlogistic fevers, taken as a natural 
family, or group. I must here repeat that it is not given as an elementary 
treatise on inflammation, with its attendant fever, which would not accord 
with the objects of a regional, historical, and practical work, and to which, 
moreover, from its imperfections, it could have no just claim ; but is in- 
tended merely as a generic presentation of facts and principles, almost 
equally applicable to all the species of phlogistic fever, and although it has 
postponed their introduction, we shall, I think, complete their history in 
less time than if views common to the whole had not been taken. Their 
generic etiology, pathology, diagnosis, and the indications and means of cure 
being understood, the respective specific histories will be much simplified 
and shortened. 



702 THE PRINCIPAL DISEASES OF THE 



CHAPTER VI. 

PHLEGMASIA OF THE CENTRAL ORGANS OF INNERVATION, BRAIN, 
AND SPINAL CORD, WITH THEIR MEMBRANES. 



SECTION I. 

ANATOMICO-PHYSIOLOGICAL INTRODUCTION. 

We may recognize the following as anatomico-physiological laws of the 
encephalic circulation : — 

Law I. — The cranium is a bony case, which, in the adult, is not perme- 
able by air, nor compressible under atmospheric pressure, nor extensible 
under the power of the heart exercised through the arteries carrying the 
blood. 

Law II. — The brain is composed of fibro-cellular substance, which con- 
sists of eighty parts in one hundred of water, and twenty of fatty and other 
animal matters, incompressible under the action of the heart; for, 1st, if 
the whole force of that organ could be exerted upon those substances it 
could not compress them ; and, 2dly, that force is not so directed, but ex- 
hausted in impelling the blood through the brain. 

Law III. — The blood itself is incompressible by any forces employed in 
sustaining its circulation. 

Law IV. — It follows, logically, that the integrity of the brain and cra- 
nium continuing, there can be neither increase nor decrease in the quantity 
of blood in the former. 

Law V. — There is a rate of velocity of circulation through the brain 
which is most proper — normal — favorable to the functions of the brain. It 
may be greatly reduced, or greatly increased, without the absolute quantity 
of blood varying. 

Law VI. — xllthough there can be no more blood in the brain at one time 
than another, much more may pass through that organ in a given time than 
in another given time of the same length, and hence the brain, in one period, 
may be more acted upon by arterial blood than in another equal period, 
notwithstanding it never has in it more or less than a given quantity. 

Law VII. — The concussion which the blood imparts to the brain is 
diminished and increased within physiological limits by several circum- 
stances : — diminished by a languid contraction of the heart; increased by 
augmented force of contraction in the heart, by the head being placed lower 
than the heart, whereby gravitation retards the return of blood from the 
brain, and augments the momentum of that going to the brain. Horizontal 
gyration, with the head in a peripheral direction, produces the same effect; 
as the centrifugal force resists the return of blood from the brain, and acce- 
lerates the flow of that which the heart is directing to it. 



INTERIOR V ALLEY OF NORTH AMERICA. 703 

Law VIII. — There should be a certain relation between the arterial and 
venous blood in the brain. This relation may be violated, and the viola- 
tion may be at the expense of the venous, or of the arterial blood. An 
excess of one, and a defect of the other, must, of necessity, arise simulta- 
neously ; for as one class of vessels becomes more turgid, the other must 
become more contracted. 

Law IX. — It results, from what is here said, that the whole venous 
system of the brain may be in a state of congestion, and that the whole arte- 
rial system may be in the same state ; but not at the same time. In the 
former case, the brain is affected by the impress of venous blood, which 
reduces its functions; in the latter by arterial blood, which exalts them. In 
both there is retarded or impeded circulation from one class of vessels into 
the other. 

Law X. — But although there cannot be universal venous and arterial 
congestion at the same time, which would imply an increase in the absolute 
quantity of blood, there may be an increase of both in a particular part of 
the brain. This local hyperemia, which exists in every case of encephalitis, 
is necessarily attended with a tendency to anaemia in some other part of the 
brain. There is no destruction of the balance between arterial and venous 
blood; but a disruption of the equilibrium of distribution.* 



SECTION II. 

CONGESTION OF THE BRAIN. 

Everybody is familiar with the phrase " congestion of the brain," or 
" congestion of the head," which to popular apprehension (both in and out 
of the profession) expresses an excessive quantity of blood within the cra- 
nium, to which they are wont to ascribe the sinister effects. I propose to 
devote a section to these alleged congestions, not going beyond those 
which present themselves in our own country, though borrowing from 
others certain facts for this illustration. Such a section is in fact a proper 
introduction to inflammations of the brain; while it affords a suitable head 
under which to arrange a number of miscellaneous affections, which concur 
in presenting a transient non-inflammatory disturbance of the functions of 
the brain, more or less intense, as the prominent condition. Our leading 

*[The progress of experimental physiology has rendered it necessary that some of the above positions 
of the lamented author should be modified. It may be advanced, that even when the amount of blood 
in the vessels of the brain is unchanged, the pressure upon their walls may vary considerably. More- 
over the quantity of cerebro-spinal fluid is variable, and this taken together with the softness of the 
cerebral substance, would admit of considerable variations in the quantity of blood contained in the 
cerebral vessels — variations necessary, as it would seem, to the ever-changing functional activity of the 
cranial viscus : or at least bearing a direct relation to that activity. Indeed it will be found that the 
author himself, in the next chapter, leans to this view of the case, and even mentions experiments of 
his own as corroborating it. — Ed.] 



704 THE PRINCIPAL DISEASES OF THE 

object will of course be to determine the extent to which this disturbance 
is dependent on congestion of the encephalic organs. 

The milder symptoms held to be indicative of this congestion are vertigo, 
tinnitus auriuni, momentary aberration of sight, dull headache, sense of 
oppression, especially in the region of the longitudinal sinus, dulness of 
intellect, drowsiness, epistaxis, flush of the face, constipation, and cold 
feet. The graver symptoms are coma, difficult articulation, numbness of 
the extremities, formication, insensibility, apoplexy, paralysis, and death. 
But the symptoms are exceedingly various. 

Among the remote causes productive of these symptoms, and consti- 
tuting so many different kinds of cerebral congestion, there are several of a 
pathological nature, and others which are external or even physiological. 

1. Plethora. — The vertigo and momentary blindness on stooping or any 
sudden movement — the heaviness in the head and lethargy, the occasional 
occurrence of apoplexy in men, and hysteria in women, promptly relieved 
by venesection in the plethora, seem to indicate cerebral congestion as a 
consequence of a plethoric condition of the bloodvessels, and a cause of the 
disturbed functions of the brain. We must bear in mind, however, that 
Andral* has ascertained that the fibrine of the blood in plethora is reduced 
about one-tenth, while the red corpscules are increased in about the same 
proportion. Now, before we adopt the conclusion that the phenomena just 
enumerated depend entirely on congestion of the brain, we must consider 
what may be the effect on the functions of that organ, of the presence in 
it of this altered blood. The most common remote causes of plethora are, 
a liberal diet, defective exercise, and protracted sleep, with a constitution 
favoring their action. It is obvious that these violations of hygienic law 
must carry disorder into the innervation, as well as augment the quantity of 
blood ; a further reason for not ascribing all the morbid phenomena to con- 
gestion. This congestion is more apt to be followed by apoplexy than cere- 
britis. The plethoric are peculiarly in danger of a serious lesion of the 
brain from a fall meal, alcoholic indulgence, strong coffee, opium, costive- 
ness, great muscular effort, and intense passion or emotion. 

Copious bleeding and purging are the immediate and indispensable means 
for relief, when signs of cerebral congestion show themselves in the ple- 
thoric. This treatment will not, however, permanently obviate the plethora, 
and if frequently repeated to the neglect of other means, will increase the 
danger of a fatal lesion of the brain. A great but gradual reduction of 
diet, abridgment of flesh, and free and even laborious exercise in the open 
air, are the appropriate remedies; to which may be added the means of 
obviating constipation, without which all others will fail. 

2. Anemia. — In this state of the system there is not only reduction of 
the entire mass of blood below the normal quantity, but a disproportionate 
loss of both fibrine and the red corpuscles, with a consequent predominance 

* Essay, p. 39-41. 



INTERIOR VALLEY OF NORTH AMERICA. 705 

of serum. * Co-existing with this condition of the blood, there is an enfee- 
bled state of the vital powers, and morbid sensibility and irritability of the 
whole system, especially the brain and heart. In this pathological state, 
congestions of the brain — so called — are even more common than in its 
opposite general hyperemia or plethora. But why should this be the case ? 
A reduced quantity of watery blood should certainly find its way through 
the brain. We cannot, I think, refuse to believe that whatever conges- 
tions of the brain occur in this condition, are consequent upon the morbid 
state of the cerebral tissue, and that while some of the symptoms may be 
referred to irregularities of the cerebral circulation, others, not less than 
those irregularities themselves, are to be ascribed to the altered sensibility 
of the brain and nervous system, and the impress on them of an altered 
and impoverished blood. Vertigo, throbbing, tinnitus, momentary blind- 
ness, and transient hysteria, apoplexy and palsy, characterize this diathesis ; 
which may be the result of a variety of causes, of which the greatest are 
excessive or long-continued alvine evacuation, secundum artem, or hemor- 
rhage. In the paroxysms of cerebral disorder consequent on this condition, 
the patient may in general be restored by stimulation of the skin, Schneiderian 
membrane, and rectum, with a moderate exhibition of diffusible stimulants 
and narcotics. To remove the general diathesis, regard must be had to the 
cause which produced it, which, if still existing, should be obviated. After 
that, a nourishing diet, exercise, fresh air, the alternate affusion of hot and 
cold water, with subsequent frictions, vegetable bitters, aperients, and 
chalybeates. 

3. Organic affections of the heart generate the symptoms of cerebral 
congestion. Loss of receiving power in the right cavities of that organ 
must generate venous congestion, and disproportionately increased force in 
the contractions of the left ventricle may create arterial congestion. Such 
congestions depend on mechanical causes, and cannot occur simultaneously, 
unless the powers which originate them are capable of pressing the cerebral 
substance into a smaller place, and filling its place with blood — of which, as 
we have seen, there is no suflicient proof. A turgescence of either class of 
vessels, necessarily produces several pathological effects. 

1. Pressure on the cerebral substance in contact with those vessels, with 
displacement proportionate to their increased diameters. This displacement 
is necessarily at the expense of the calibres of the vessels in the neighbor- 
ing parts. Now, this condition may be suddenly induced, and we cannot 
doubt that many of the symptoms of congestion may be thus generated. 

2. A congestion of the kind we are now considering must necessarily 
retard the circulation through the brain. This is the violation of a physio- 
logical law, and cannot but contribute to the production of some of what are 
called the effects of congestion. 

* Andral'g Essay. 
vol. ii. 45 



706 THE PRINCIPAL DISEASES OP THE 

3. The retention of blood beyond its proper time in the engorged vessels, 
which cannot fail to irritate or depress the functional energy of the cerebral 
substance, and thus originate some of the symptoms which are referred to 
mere vascular distension and consequent pressure. These remarks apply to 
venous accumulation. In the case of arterial congestion from excess of 
power in the left ventricle of the heart, the symptoms may not result so 
much from the pressure of the distended vessels as from the exciting in- 
fluence of an excess of arterial blood. 

4. A part of the symptoms, moreover, may result simply from the exces- 
sive impulse of the column of projected blood, sent by the hypertrophied 
left ventricle. 

5. A portion of the symptoms may be the result of a sympathy of the 
brain with the diseased heart. 

Thus we find that there are various modes in which an organically dis- 
eased heart may carry disease into the brain and develop what are called 
symptoms of congestion. 

6. Certain gastric and intestinal disorders generate a variety of cerebral 
symptoms. Dyspepsia, especially when accompanied with acidity of the 
stomach and torpor of the bowels, is a frequent cause of vertigo, visual per- 
versions, cerebral weight and oppression, obtuse pain through the substance 
of the brain, and acute pain in the membranes of the cranium ; a lively 
perception of the action of the heart upon the brain j morbid vigilance or 
drowsiness, irascibility or indifference, dulness of intellect, hysteria, convul- 
sions, hypochondriasm, melancholy, and even madness, the immediate or 
proximate cause of which is held to. be sanguineous congestion. 

Now, in these disorders of the functions of the brain from disease in the 
stomach and bowels, there is no obstruction to the return of blood from the 
former, nor increased projection of that fluid into it. The alleged conges- 
tion in short does not depend on a mechanical cause ; why then should it 
take place ? If it really exists, its immediate cause must be a morbid con- 
dition of the encephalic solids, either the cerebral substance or the vascular 
tissue ; and this condition can be nothing else than a sympathy of these 
parts with the digestive organs. The mechanical theory of congestion over- 
looks this diseased state of the encephalic solids, on which many, perhaps 
most of the symptoms of cerebral disease may depend, and looks only to the 
congestion of which it may be the cause, but to which none of the symptoms 
existing before it can of course be ascribed, though it may be the cause of 
many new ones. In the present state of pathology, it is, perhaps, impossible 
to analyze these symptoms, and distinguish those which depend on the 
sympathetic irritation of the encephalic tissues from those which arise from 
the congestion or vascular irregularities which that irritation establishes. 

5. Narcotics. — As these (at least most of them) do not much increase the 
force of the heart and the vis a tergo of the circulation, the cerebral conges- 
tion which they occasion cannot be ascribed to a mechanical cause, and must 



INTERIOR VALLEY OF NORTH AMERICA. TOT 

of course depend on a previous state of that part of the brain in which it 
occurs. If the narcotic draught should be large or greatly concentrated, 
this primary effect on the brain may prove immediately fatal without the 
intervention of congestion. Such is the effect of prussic acid. The same 
is true of alcohol. Thus, Dr. Frederick Ridgely, of Lexington, informed 
me that he once saw a man who had so far recovered from a fever as to be 
able to walk about, drink half a pint of whiskey, and fall down dead. In- 
deed, the whole therapeutical and toxicological history of narcotics proves 
that they exert a powerful and deleterious impress on the brain, of which, 
when death does not immediately occur, congestion maybe the consequence. 
The hydraulic theory diverts our attention from the former — the primary, 
and fixes it on the latter, which is but secondary. 

6. Gastric Repletion. — The effect of this on the brain is established by 
the general experience of mankind. It is a physiological law that an ex- 
travagantly large meal shall affect both the heart and brain. In the pro- 
duction of congestion in the latter, it sympathetically disturbs or depresses 
the cerebral tissues, while the heart, increased in its energy, propels the 
blood with augmented momentum. The drowsiness and every other sinister 
cerebral symptom in this case is commonly ascribed to congestion ; but it 
is worthy of remark, that there are two periods in the twenty-four hours in 
which such a meal is not followed by drowsiness, and two in which it is. 
A hearty breakfast, and a hearty supper taken at nightfall, are not produc- 
tive of stupor and sleep, but taken soon after mid-day or late in the evening, 
the propensity to sleep is often urgent, and serious lesions of the brain some- 
times occur in that state. Xow as the dynamic influence of the heart over 
the brain should be the same after each of the four meals, it would appear 
that some other pathological cause is in operation, and that the danger does 
not consist altogether in the injection of the brain. 

T. Abstinence. — Starvation, while it constantly diminishes the quantity 
of blood, and reduces the power of the heart, is well known to generate 
cerebral symptoms identical with many of those ascribed to congestion, 
such as vertigo, headache, delirium, mania, convulsions, and even apoplexy.* 
Captain Fremontt informs us, that in the month of February, 18-i-i, when 
his party was crossing the Sierra Nevada, in Xorth California, at the ave- 
rage height of 9,000 feet, in latitude 38°-9°, after many days of fatigue, 
exposure to cold, and a diet reduced almost to famine, Towns, one of his 
men, " became light-headed, and wandered off into the woods, not knowing 
where he was going." Three days afterwards, when they had descended to 
the banks of a small icy river, he went in to swim as if it had been summer. 
About the same time, Derosier, another man, was separated from the party 
on a special duty, and wandered, cold, hungry, and fatigued, for forty-eight 
hours. He overtook the party, and still was in such a mental condition, 

* Cyclop, of Prac. Med. vol. i. p. 22. 

f Explor. Exped. to Oregon and California, 1843-4, p. 240. 



708 THE PRINCIPAL DISEASES OP THE 

"that he imagined he had been gone several days/' and believed the camp 
to be the same he had left. In both cases this delirium passed away from 
increase of heat and nourishment. 

When the brain has been ♦examined after death from starvation, it has 
been found more vascular than other parts of the body • it has even 
been pronounced to be in a state of inflammatory congestion, and the ven- 
tricles have sometimes contained serum beyond the usual quantities. But 
in these cases, we are not at liberty to doubt that the disturbance of the 
functions was referable to the state of the cerebral substance, independent 
of congestion. That the organ should appear to be in a state of congestion 
is not remarkable, seeing that the pressure of the atmosphere must of neces- 
sity keep blood enough in the cranium to prevent a vacuum • but if we grant 
a congestion not to be thus explained it must be ascribed to the previous con- 
dition of the cerebral substance, and classed with the pathological effects 
rather than causes. 

8. Solar Heat. — Sun-stroke or coup de soleil is generally believed to con- 
sist essentially in cerebral congestion. Andral* has given two cases in 
which there was not in fact congestion of the brain, though they are pre- 
sented as examples of that disease. Dr. Dowler, of New Orleans, where 
death from insolation is not uncommon, denies the existence of congestion 
of the brain, but affirms that the cause of death is to be found in congestion 
of the lungs. Nevertheless the phenomena of this affection are those of 
cerebral diseases, and no doubt there is sometimes congestion of the brain, 
sometimes of the lungs, or even of other organs. But why should we 
ascribe the death of the individual to this congestion, and overlook the 
antecedent circumstances ? The experiments of Dr. Edwards,f show that 
animals drowned in warm or hot water cannot be revived like those who 
had been submerged in cold water, for the same length of time. Also that 
frogs which may live twenty-four hours in water but little* above the freez- 
ing point, die in a few minutes if submerged in that which has a tempera- 
ture eight or ten degrees above the freezing point. These and other facts 
show that heat tends to exhaust the irritability and sensibility of the organs, 
and to this we must ascribe much of the sinister influence of insolation. 
The same and other experimenters! have shown that before death takes 
place from exposure to a hot atmosphere, the bodies of the mammalia 
and birds may be raised in temperature 10° or 12°. It cannot be denied 
then, that some increase of heat must take place in both the blood and solids 
of the body, in those who move in our summer atmosphere exposed to the 
sun, which must disturb their functions. That congestions of the brain 
and other organs may be generated under this powerful action of caloric, is 
not remarkable; but we are not at liberty to overlook the pathological cir- 
cumstances which precede them, and of which they are but the effects. 

* Clin. Med. p. 75. f Influence of Phys. Agents on Life. + Miller's and Carpenter's Phys. 



INTERIOR VALLEY OF NORTH AMERICA. 709 

Fatal cases of sun-stroke occur as far north as the Lakes, but according 
to the Army return (p. 334), are more frequent in the South. 

From New Orleans to Quebec, the thermometer, on hot days, rises in the 
shade from 95° to 105°, and in the sun many degrees higher. The maxi- 
mum heat is from 2 to 3 p.m. The effect of this temperature is most op- 
pressive and pernicious immediately before a thunder-storm, as the dew point 
then interferes with exhalation from the surface of the body, and thereby 
prevents its cooliDg. As almost every summer brings forth days of this 
kind in an increasing ratio, as we pass from North to South, I have often 
felt surprised that the number of cases of sun-stroke and other cerebral dis- 
eases, of which the heat might be an exciting cause, should not be greater 
than it actually is. A majority of our physicians have never seen a case of 
coup de soleil. 

It is well known that oxen, especially when fat, if overworked on such 
days are apt to die. The theory of their death, which prevails among the 
people, is that their kidney tallow is melted. 

Individuals who are prone to apoplexy, and those who have eaten hearty 
dinners should guard against exposure to such a sun. An umbrella is of 
doubtful advantage, as the radiated caloric from the earth is intercepted by 
the concave of the umbrella, and thrown upon the head. He who perspires 
copiously and drinks freely of water is least likely to suffer. Ardent spirits 
under such circumstances, if they increase the perspiration, may do no harm. 
If the skin remain dry under their use, the danger is greatly increased. 

9. Cold. — The first effect of cold applied to the cutaneous surface is a 
certain degree of reaction, or resistance of the vital forces ; more blood 
advances to the surface, and the calorific function becomes more active. 
This condition accompanied with a slight ruddiness soon begins to fail. The 
heat is carried off faster than it is developed, and the heat-produciDg func- 
tion is impaired ; the surface then begins to cool, the slight rose-color gives 
place to a bluish tint, indicative of capillary stagnation, or to pallor from 
anemia. The parts are now sensibly cold, reduced in size, numb, given to 
aching, and greatly enfeebled. The heart begins to fail, the voluntary 
powers are equally impaired, the blood is no longer sent beyond the visceral 
circles, but accumulates in the organs, where it finally stagnates, creating 
congestions which are literally the effect of the loss of that animal heat in 
both the solids and fluids, which is the indispensable condition of life. In 
a comparatively early stage of this refrigeration, sleepiness comes on, and 
the cause continuing to act, a deep and fatal coma at length ensues. It is 
entirely gratuitous to derive these remarkable effects entirely from the con- 
gestion of the brain, which itself is but one of them. This drowsiness and 
torpor if not identical with, is at least analogous to that of hibernation, 
which several of the mammalia experience every winter.* It does not appear, 
however, that respiring an air reduced to the temperature of — 20°, — 30°, 

* Miller's Phys., by Bell, p. 79. 



710 



THE PRINCIPAL DISEASES OP THE 



— 40°, or even — 50°, the cutaneous surface being adequately protected with 
furs and woollens, will produce these effects.* 

While excessive heat excites great activity of function, with speedy ex- 
haustion of irritability, cold, after a transient reaction, reduces the energy 
and activity of the functions, but without exhausting the vital properties 
to the same degree, and hence persons in apparent death from this cause 
are sometimes restored to life. But they never revive spontaneously like 
the hibernating animals ; nor will an individual who falls asleep from cold, 
which continues to act upon him, ever awaken, if left to himself. 

In addition to its immediate and legitimate effects in destroying life, cold 
is supposed to be both a predisposing and an exciting cause to various lesions 
of the brain, which as we have already seen is assumed of heat. Thus ac- 
cording to Andral,")* cerebral congestions " find an occasional cause of de- 
velopment in the two extremes of temperature, and are reduced to their 
minimum of frequency by the influence of a mild and uniform temperature/'' 

In confirmation of this, after referring to the statistical researches of M. 
Falret in Paris, he gives, from his own practice, the distribution throughout 
the year of 114 cases, as follows : — 

December, January, and February, 50 cases; March, April, and May, 31 
cases; June, July, and August, 36 cases; September, October, and Novem- 
ber, 17 cases. 

I have transcribed this table for the purpose of comparing it with another 
formed from the statistics of our Army, so often quoted. Its returns, how- 
ever, present " diseases of the brain and nervous system/' under a single 
head. 

TABLE OF CEREBRAL AND NERVOUS DISEASES, SHOWING THE ANNUAL AVERAGE NUM- 
BER OF CASES PER THOUSAND OF MEAN STRENGTH, — THE RETURNS BEING FOR TEN 
YEARS. 





1st 

QUARTER. 


2d 

QUARTER. 


3d 

QUARTER. 


4th 

QUARTER. 


AGGREGATE 
OF THE 
TEAR. 


Eight Posts above lat. 43° N., . 
Seven Posts between the 33d ) 

and the 43d deg. N. lat, . $ 
Ten Posts below the 33d deg. \ 

N. lat., $ 


9-2 

7-0 

15-4 


10-4 

7-7 

16-0 


8-1 

7-9 

22-3 


7-1 

8-0 

20-5 


34-8 
30-6 

74-2 



It appears from this table that what are termed " diseases of the brain and 
nervous system," in the Army reports, are most prevalent in the South, 
after which comes the North, and, lastly, the middle latitudes ; the numbers 
being 74-2 cases, for every thousand troops at the southern posts; 34-8 in 
the northern; and 30-6 at the middle. As the northern differs so little 



* See the Voyages and Travels of Ross, Parry, Franklin, and Back. 



t Clin. Med. p. 77. 



INTERIOR VALLEY OF NORTH AMERICA. 711 

from the middle latitudes, we may say that the heat of the South seems 
more productive of cerebral disease than the cold of the North. In com- 
paring the numbers which express the relative liability of the different 
quarters of the calendar year, we find those of the middle latitudes remark- 
ably uniform ; those of the North do not indicate the sinister influence of 
winter in any striking degree ; but those of the South show decisively the 
influence of summer. If we add up the averages of each quarter, for 
all the posts extending from Key West to Fort Brady, through 22° of 
latitude, the results are, — 1st quarter, 31*6; 2d quarter, 34-1; 3d quarter, 
383; 4th quarter, 35-6. Thus, the third quarter, embracing July and 
August, presents the greatest number; the first quarter, comprehending 
January and February, the least ; while the spring and fall, or the second 
and fourth, are nearly equal. These results, it will be seen, are at vari- 
ance with those of Andral. No close comparison can, however, be drawn, 
for his observations were made in civil society, while the army returns ex- 
clude women, children, and aged men. Nevertheless, they are not without 
their value, as they show the influence of diversity of climate on a parti- 
cular class of men, who, in everything else, are placed under similar 
hygienic circumstances. 

It is a current opinion in this country, that extreme cold is apt to be 
fatal to aged persons, by inducing congestion of the brain, ending in apo- 
plexy. This may be admitted without impeaching the accuracy of the army 
returns, inasmuch as the service excludes old men. A nutritious diet, 
taking care not to overload the stomach at night', open bowels, warm 
clothing, and especially the proper clothing of the head and lower extremi- 
ties, are the best means of averting this sinister effect. 

10. Mental Excitement. — Under this head may be included not only the 
inordinate exercise of the intellectual faculties, but all intense or protracted 
emotion or passion. The whole exert an influence on the brain and the 
circulation of blood through it. Every physiologist knows that when an 
organ is roused into functional activity, it receives and circulates more than 
its ordinary quantity of arterial blood, and that by over stimulation it may 
at length become inflamed. Now, this is not more true of the stomach, 
when subjected to repletion with its appropriate stimuli, food and drinks, 
than it is of the brain, when overworked or agitated by intellectual or emo- 
tional excitement. Thus an intense exercise of the mind in childhood may 
carry an irritation into the hemispheres of the brain, accompanied by con- 
gestion, and at length occasion hydrocephalic inflammation, or convulsions. 
Many precocious and promising children have been destroyed in this way. 
At a more advanced period, too much application, which, however, is not 
common among our young men, produces similar effects. In the meridian, 
and throughout the decline of life, great occasional exertion of mind is fol- 
lowed by apoplexy or cerebritis from congestion. This is, perhaps, oftenest 



712 THE PRINCIPAL DISEASES OF THE 

the case in those who in early manhood were dyspeptic. An illustration of 
this variety of cerebral congestion may be found in the following 

Case.— A physician, in one of the towns of the interior, was dyspeptic 
from the age of twenty-one to thirty-three or four, when the paroxyms of 
that malady began to diminish in force and frequency. At the age of 
thirty-nine, he was called upon for six or eight weeks to make a great and 
unwonted effort of mind ; at the end of which time he felt an unnatural pro- 
pensity for locomotion, and found it rather difficult to compose himself to 
sound sleep at his usual bedtime. On relaxing in his application of mind, 
these effects underwent some abatement ; but through tlie remainder of the 
winter and the ensuing spring, he often felt a sense of weight or oppression 
in the upper part of the head. With the access of hot weather this feeling 
increased until it became almost constant, and was often accompanied with 
drowsiness or high mental excitement, his scalp frequently felt as if shrunk 
up and contracted over the cranium, and his feet seemed to him to be the 
seat of an acrid heat, when, in fact, they were too cool. Always prone to con- 
stipation, his bowels were now more torpid than usual; but his appetite was 
regular, his pulse was nearly natural, and he did not experience fever. In 
the latter part of June the cerebral symptoms increased in urgency, and a dull 
pain ensued, with great sense of tightness about the head, a loquacious pro- 
pensity, and a strength and vividness of mind, which he had scarcely ever before 
displayed. He had taken a cathartic which did not operate, and it was now 
judged advisable to draw blood. This was done from a large orifice, the patient 
sitting up, and the discharge was allowed to continue until he felt the approach 
of syncope, which was averted by his lying down. The quantity drawn was 
forty-two ounces. It was not sizy. I need not, for our present purpose, go into 
minute details of the subsequent symptoms and treatment. This first bleed- 
ing was followed by a decided abatement of the cerebral symptoms, and a 
better operation of the cathartic medicines. But although the symptoms of 
actual cerebritis or meningitis were never developed, feelings of oppression, 
weight, and constriction continued to recur, and were combated by vene- 
section, cupping, arteriotomy in the temple, till about one hundred ounces 
in all were lost, by cold applications, and then blisters to the head, and by 
repeated cathartics. At length there arose a state of constitutional exhaus- 
tion, accompanied by feelings of nervous irritation, demanding stimulants, 
tonics, nutrients, and exercise, under which he recovered a tolerable state 
of health. He remained subject, however, to attacks of a kind similar to, 
but less violent than the one described, for several years. In the more 
severe, he lost blood, which was never sizy, and almost always followed by a 
sense of deep nervous exhaustion, requiring diffusible stimuli and narcotics 
for its removal. Gradually he ceased to employ the lancet, and in general 
could arrest the attack by an early resort to active cathartics. But although 
more than twenty years have elapsed since the first attack, he is still sub- 
ject to a feeling of weight and oppression in the region of the longitudinal 



INTERIOR Y ALLEY OF NORTH AMERICA. 713 

sinus, with drowsiness, especially in the afternoon, even when he has eaten 
no dinner, though both are augmented by that meal. 

This seems to have been a case of cerebral congestion, which neglected, 
might have terminated either in apoplexy or inflammation. That it arose 
from over-working of the brain, previously rendered irregular in its circula- 
tion from sympathy with a dyspeptic stomach, is extremely probable. The 
temperament of this gentleman was of a kind to defend him against inflam- 
mation, and his age and anatomical conformation were an equal protection 
against apoplexy. 



CHAPTER VII. 

PHLEGMASIA OF THE CENTRAL ORGANS OF INNERVATION, BRAIN, AND 

SPLXAL CORD, WITH THEIR MEMBRANES. 



SECTION I. 

PREVALENCE AND CAUSES. 

1. It would be interesting to ascertain the comparative prevalence of 
original simple inflammation in the organs of the cranium, thorax, and 
abdomen, in the different parts of our Valley ; but in the present, scarcely 
germinal condition of our vital statistics, such a comparison is impossible. 
Leaving the thoracic and abdominal inflammation for their appropriate 
heads, I may say in general terms that the cerebral are of much less fre- 
quent occurrence, but of more fatal issue than either of them. This, if I 
am not mistaken, is according to the experience of our physicians, and in 
comparing the number of deaths with the number of cases in the British 
army in Canada, and the Windward and Leeward (West India) Islands* I 
find it confirmed. Thus, through twenty years, there was one death for thirty 
cases of thoracic, eleven cases of abdominal, and nine cases of cephalic in- 
flammation. These returns relate to men, but from the known mortality 
of cerebral inflammation in children, if a proportionate number of their 
attacks had been included, the rate of mortality would be still higher. "We 
should not refer the dangerous character of cerebral inflammation to the 
causes which produce it, but to the anatomical and physiological peculiarities 
o'f the brain, to which reference will be made hereafter. 

While thoracic inflammations prevail more in the North, and abdominal 
in the South, the cerebral appear to occur with considerable uniformity in 
all our latitudes j showing, that of the whole they have least connection with 

* Tulloch's Report. 



714 THE PRINCIPAL DISEASES OF THE 

climate. My own observations lead to the conclusion that they are more 
frequent in town than country; but as the supposed causes abound in the 
former more than the latter, the mind is of course busied in favor of a con- 
clusion, which, until established by statistics, should not be regarded as 
final. These causes were so fully enumerated and discussed in Chapter II., 
on the etiology of the phlegmasise generally, that little need be said in this 
place. 

Gluttony and drinking may be either predisposing or exciting causes of 
cerebral inflammation. The former is, I think, an unquestionable cause of 
the disease in children who take but little exercise. In youth and man- 
hood, either or both exert a pernicious influence. In old age, they generate 
apoplexy and palsy rather than inflammation. Undisciplined passions and 
intense or protracted study co-operate with the causes which have been 
named, and may even of themselves respectively excite inflammation. Falls 
and blows producing concussion of the brain or spinal cord, are effective 
causes, which prevail on land and water, in city and country, and are every- 
where increasing with the eager extension of our business and new settle- 
ments ; in which the forest is to be supplanted with the products of art, by 
a people who look much more to success in their enterprises than to the 
safety of their persons. 

But sedentary employments and bodily inactivity may indirectly produce 
cerebral inflammation; for as muscular exertion invites blood into the ex- 
tremities, and promotes its transit through the brain, the neglect of such 
exercise may favor congestion of that organ. Sedentary occupations, more- 
over, lead to costiveness, which, however, brought on, predisposes to cere- 
bral hypersemia and subsequent inflammation. 

As several of the causes which have been named are rather increasing 
than diminishing, cerebral inflammation is likely to become more frequent 
than at present, and should therefore receive a careful consideration. 

2. What has been said relates to cerebral inflammation as a primary 
affection, but we must not forget that it is still oftener a secondary disease. 

1. It is frequently developed, as we have seen, in the course of our 
typhous, exanthematous, erysipelatous, yellow, and autumnal remittent 
fevers, when it generally proves fatal. 

2. In the form of duramatritis it occurs as a metastasis of rheumatism 
from the joints; a more manageable case than those just mentioned. 

3. Active or excentric hypertrophy of the heart, by over injecting the 
brain, frequently originates inflammation. 

4. In advanced stages of phthisis it is not uncommon ; and I have seen 
a fatal case which supervened on extensive tuberculization of the lungs, 
before the suppurative stage had set in. In these cases there is doubtless 
a deposit of tubercles in the brain ; and they may be classed with the cases 
of original tubercular cerebritis (or incurable hydrocephalus) of children. 

5. I have seen many metastases of inflammatory cholera infantum to the 



INTERIOR VALLEY OF NORTH AMERICA. 715 

brain. It seems probable that the organ was tubercular; for they have 
generally proved refractory and fatal. Sometimes they begin almost as 
soon as the gastric affection. In other cases they arise insidiously and 
slowly, the cholera having become chronic. I have not seen the cholera 
morbus of adults undergo this metastasis. 

6. The cerebritis following on the collapse of epidemic cholera, is but 
too well known to us all. 

7. Apoplexy is often followed by inflammation, especially when hemi- 
plegia has been induced ; and its superadded lesions are doubtless one of 
the causes which render the latter infirmity protracted, and occasion the 
imbecility so often associated with it. 

8. Inflammation of the dura mater and its associated arachnoid mem- 
brane sometimes follows on otitis, and suppuration of the internal ear. 

9. Cerebral imflammation has followed on the drying up of ulcers of the 
scalp. There was probably an extension of the inflammation to parts 
within, and a consequent cessation of that without. But the current 
opinion in the profession that powerful applications, in certain chronic dis- 
eases of the scalp, are followed by metastasis, deserves to be respected. 

In my own practice secondary has been more common than primary cere- 
britis. While the brain is more secluded than the organs of the other 
cavities from external causes, it seems more liable than any of them to par- 
ticipate in the inflammations of other parts; which, perhaps, arises from 
their reactions upon it, as an organ presiding (unequally) over the functions 
of the whole. 

It is worthy of remark, that the spinal cord is much more seldom in- 
flamed than the brain, either primarily or secondarily, which should proba- 
bly be ascribed to its greater simplicity of function, and consequent inferior 
supply of arterial blood. 



SECTION II. 

CLASSIFICATION AND DIAGNOSIS. 

I. Classification. — When an individual labors under fever, thoracic 
pain, cough and difficult respiration, we know that his lungs or their invest- 
ing membranes are inflamed. These are generic symptoms, and tell of pneu- 
monic inflammation ; but do not inform us whether it is bronchial, cellular, 
or pleuritic. To determine this we resort to other phenomena — vital and 
physical — which being less general, and therefore serving as specific cha- 
racteristics, become the means of differential diagnosis. If we apply this 
illustration to the phlegmasiae of the brain and its meninges, we find that 
a considerable number of reliable generic symptoms are at hand, but that 
the guides to a specific distinction are entitled tcylittle confidence. If this 
has been perceived and acknowledged by the great pathologists, who have 



716 THE PRINCIPAL DISEASES OP THE 

made cerebral diseases a special study, how much more must we, in the 
humbler and general walks of the profession, feel embarrassed by it. Hap- 
pily, however, it is even less important in cranial than thoracic imflamma- 
tion to decide on its exact seat before entering upon its treatment. 

The causes of complexity in the symptoms, resulting from inflammation 
of the brain and its membranes, are the complicated functions of that organ ; 
the sustaining and governing influence which it exerts over all the func- 
tions of animal, and many of organic life; the reaction which almost every 
other portion of the organization exerts upon it, and the disturbance of all 
or many of its functions from a morbid condition of any one of its parts. 
The semeiography which results from the modifying influence of these 
physiological conditions would extend through many chapters, and yet leave 
combinations of symptoms undescribed. Indeed, there is no department of 
semeiology in which generalization is so difficult — in which the same symp- 
toms so often result from different pathological conditions, or different 
symptoms from the same condition, or in which every case displays so 
much that is peculiar to itself. Thus, almost every symptom has in differ- 
ent cases been absent ; and if one were to attempt the construction of a 
generic character, he would find it necessary to take many which are not 
invariably but generally present. 

It is common to divide inflammations of the cranial organ into meningeal 
and cerebral, corresponding, for example, to peritoneal and parenchymatous 
inflammation of the liver ; but this is a division which cannot be expressed 
by the symptoms. 

1. The dura mater in structure, functions, and anatomical relations, must 
be considered apart from the arachnoid and pia mater. The former belongs 
to the cranium, the two latter to the brain. Most of its inflammations are 
of limited extent, and connected, in origin, with lesions, or diseases of the 
bones, to which it is attached ; and, of course, the symptoms of duramatritis 
or cranio-duramatritis, as it might generally be called, are not identical with 
those which result from inflammation of the involucra of the brain. When, 
however, the inflammation extends from the serous surface of the dura mater 
to that of the hemispheres, as in pleuritis pulmonum from pleuritis costalis, 
other symptoms are of course developed. 

2. The gray, vesicular surface of the convolutions has a vascular connec- 
tion with the membranes, as intimate as with the white fibrous tissue beneath, 
and participates in the inflammation of those membranes, or otherwise 
suffers from their morbid condition, more certainly, even than from inflam- 
mation seated in the depths of the cerebral substance. We cannot, then, 
distinguish vesicular or superficial cerebritis from meningitis by the symp- 
toms, but must contemplate them together, and might not inappropriately 
apply to the two, the term cerebro-meningitis. It is true that the vesicular 
covering does not always participate in the inflammation of the membranes, 
but this can never be determined by the symptoms, which are at least to 



INTERIOR VALLEY OF NORTH AMERICA. 717 

ordinary observation the same, whether the complication exist or not. Here 
then we have a second, and by far the most common seat of encephalic in- 
flammation. Why it is the most common results from two causes, first, the 
great arterial vascularity of the pia mater, and second, the vascularity and 
ever active functions of the vesicular substance. 

3. The third is the white fibrous mass of the hemispheres, their fibrous 
commissures, and their fibro-vesicular ganglions. To this inflammation the 
term cerebritis is strictly applicable. It is not always, however, confined 
to the interior of the brain, but frequently reaches the vesicular coping 
of the hemispheres or the investing membranes, especially of the basilar 
portion and the ventricles. In this complication its symptoms approxi- 
mate it to the other variety ; but when restricted to the pulpy substance 
it presents phenomena which differ in several respects from those of the 
other variety. 

II. The duration of the forming stage of encephalic inflammation,* has 
in different cases the greatest possible variety. When it results from exter- 
nal violence, sudden changes of weather, or a debauch, it may be developed 
instanter, but when occasioned by less energetic causes, its advances are 
often slow and insidious. Even the causes just mentioned may create but 
a predisposition, and lay the foundation for a future development. During 
this protracted forming stage there is no fever, and the impending inflamma- 
tion is too often not foreseen. It is quite impossible to enumerate all the 
symptoms attendant on this period of lengthened incubation ; and I shall 
limit myself to the following observations : First. The most constant 
symptoms are found in the animal functions, and consist of headache, dis- 
turbed and unrefreshing sleep, an occasional feeling of heaviness or light- 
ness in the head, impatience and irascibility of temper, unsteadiness of at- 
tention, and diminished capacity for intellectual labor; but in some instances 
the mind displays unwonted and sustained activity. In a case which fell 
under my observation many years since, a gentleman, had shown for several 
months extraordinary strength and vivacity of mind, and immediately 
before it became necessary for him to lose forty ounces of blood at a single 
operation, he manifested an ability which surprised both himself and his 
friends. Second. The appetite is generally capricious, and the bowels still 
more frequently torpid. Third. Fits of head-suffusion, or determination to 
the brain, as it is called, are occasionally experienced, with a tendency to 
vertigo, especially after eating a full and stimulating meal, or indulging in 
the use of strong coffee or alcoholic drinks. Fourth. The feet are apt to 
fail in temperature, and the functions of the skin become impaired. Fifth. 
During this period hemorrhoidinarians, are likely to remain exempt from 
their habitually recurring malady. Sixth. Chronic inflammations and 
ulcers of the scalp are apt to cease. 

* I shall employ this Greek term as a generic expression for all the intercranial inflammations, using 
the Latin cerebral and cerebritis for those which are confined to the parenchyma of the organ. 



718 THE PRINCIPAL DISEASES OP THE 

There are two interesting points of view under which we should contem- 
plate the symptoms which have been enumerated. First. They may not be 
followed by inflammation, as appears from their spontaneously ceasing. 
Second. The inflammation set up may be so mild and limited, as not to 
generate fever, and, therefore, not be suspected of existing, though it may 
gradually disorganize the parts in which it is seated, and be followed by 
mania, epilepsy, or paralysis. 

III. Diagnosis op Duramatritis. — This subject belongs largely to 
Surgery, and I shall not dwell upon it. When external violence has been 
the cause, pain in and beneath the injured part, accompanied by fever, are 
significant of inflammation. Delirium may or may not be present. From 
local congestion and effusion, coma may occur at an early period. When 
the disease is but an extension of inflammation from the internal ear, the 
previous history affords aid in diagnosis, the pain is often intense, and fre- 
quently extends from the part affected to higher portions of the membrane ; 
as in the other case delirium is not invariably present, and coma often occurs 
without being preceded by that state of mind. Rheumatism occasionally 
attacks the dura mater, but less frequently than the fibrous membranes of 
the heart. The pain is severe and diffused, and the brain being sympatheti- 
cally active, delirium with restlessness may supervene. Thus a distinctive 
diagnosis is not practicable without referring to the history of the case. 
As rheumatism is a recurring disease, it may sometimes return in the dura 
mater, and its true character be overlooked. 

IV. Cerebro-Meningitis. — Of all the forms of encephalitic inflamma- 
tion this is the most frequent. Its common appellations are, arachnitis, 
and " inflammation of the brain," the latter expression being used indeter- 
minately for an inflammation of any tissue within the cranium. When 
fully developed, it generally assumes an acute and violent character. The 
pain of the head is intense, especially in the anterior part, and is invariably 
increased by succussion, pressure, or a horizontal posture. When quiet, the 
patient frequently assumes for his head some definite position, which appears 
to give him a certain degree of relief. Delirium and great restlessness are 
early symptoms. The eyes are morbidly sensible to light, the pupils con- 
tracted, and the conjunctivae more or less congested. The sensibility of the 
ears is equally exalted. The preternatural heat of the head is generally 
accompanied with coldness of the feet, in which, however, there is some- 
times a feeling which makes the patient complain that they are hot. The 
carotid arteries are distended and tense. The heart is invariably affected. 
In some cases the pulse is tense, frequent, and regular ; in others more fre- 
quent still, smaller, intermittent, and so variable as to change its character 
during the same examination ; finally, it is now and then preternaturally 
slow. The tongue, in most cases, is white; the stomach is often irritable, 
and vomiting is not uncommon; the bowels, almost without exception, are 
costive, and even torpid. The skin, of course, is dry, and I have frequently 



INTERIOR VALLEY OF NORTH AMERICA. 719 

seen the function of perspiration so completely suspended that venesection 
to approaching syncope has not brought out the characteristic moisture of 
the upper lip. Now and then, especially in children, convulsions, and 
even coma, occur in the midst of the symptoms which have been narrated. 

The duration of the stage which has been described varies from a few 
days to as many weeks, according to the intensity of the symptoms. The 
transition to the third and final stage (when the tendency is to death), 
whether rapid or gradual, is characterized negatively by an abatement in 
the phlogistic intensity, by blunted sensibility, the supervention or increase 
of coma, dilated pupils of both, but in some cases of one eye only, strabis- 
mus, or, in its stead, a set of both eyes in the same direction, the axis 
remaining parallel. The sensibility of the optic nerves, always blunted, is 
sometimes extinguished. The external engorgement increases, and a muco- 
puriform secretion oozes from between the lids, or overspreads the cornea. 
The delirium passes into a kind of dementia, with muttering. Yet I have 
seen the patient wild and incoherent till near the close. Ordinary subsultus 
tendinum occasionally occurs ; partial, or even general convulsions are fre- 
quent, and paralysis, generally of one side, now and then happens. The 
heart participates largely in this disorder of the organism, loses its energy, 
and becomes every hour more frequent, feeble, and vacillating in its action. 
The irritability of the stomach is now succeeded by torpidity, and the con- 
stipation of the bowels, in some cases, by colliquative diarrhoea, of the 
existence of which the patient becomes insensible before death. 

When the symptoms which have been narrated occur, we may declare the 
case to be cerebro-meningitis. But many cases do not present the whole, 
and when the disease is of a mild grade, we are especially liable to error. 
The development of the third and last stage, will, it is true, at all times 
assure us ) but this knowledge, not less than that afforded by post-mortem 
inspection, comes too late. I have spoken of the great importance of de- 
tecting encephalic inflammation in its forming stage, and may here insist 
that it is not less important to detect it in the inflammatory ; for if that be 
allowed to advance far, the fate of the patient is sealed. 

Y. Simulating Afeections. — 1. A plethoric condition of the general 
system, especially when accompanied with constipation, may be attended 
with pain and heaviness of the head, vertigo on stooping or turning sud- 
denly round, drowsiness, and dulness of mind. Such a condition might be 
mistaken for inflammation, when there is only simple distension of the 
vessels of the brain, with liability under external influences to congestion, 
especially of the venous sinuses. The absence of fever will, in general, 
enable us to distinguish such a case from one of inflammation. 

2. Mere constitutional irritation, accompanied by neuralgic pain of the 
pericranium or dura mater, may be mistaken for cerebro-meningitis, and 
the frequency of pulse, so often attendant on this condition, may be taken 
for that of fever. A thorough acquaintance with the phenomena of inflam- 



720 THE PRINCIPAL DISEASES OF THE 

mation, scarcely to be acquired except at the bedside through a series of 
years, is necessary to protect us from diagnostic error in such cases. The 
hot skin and thirst of inflammatory fever are wanting; the frequency of 
pulse sometimes ceases suddenly, and is as suddenly renewed, with the 
abatement or revival of the morbid contractility of tbe heart; the tongue is 
seldom white with fur, and often looks pale and flabby; the bowels are not 
particularly torpid ; external compression mitigates the headache ; and, in 
some cases, there is sighing, apprehension, increased secretion of urine, 
and other hysterical symptoms. Should blood be drawn in these cases, it 
may be sizy, yet the reduced size of the clot will account for that appear- 
ance without supposing a state of hyperinosis. 

3. Every physician has met with cases of dyspepsia, accompanied with so 
much sympathetic suffering of the brain and organs of sense and motion as 
to suggest cerebral inflammation. Headache, dizziness, unsteadiness of 
vision, muscas vlitantes, congestion of the conjunctivae, spasmodic twitching 
of the muscles of the eyelids, and sometimes epileptic convulsions may 
occur. The bowels, at the same time, are torpid. The pulse may or may 
not be preternaturaliy frequent. If the dyspepsia be phlogistic (chronic gas- 
tritis), the skin may be unnaturally warm, and the tongue more or less 
covered with a white fur. In all cases there is thirst. The question, 
whether the cephalic symptoms are primary or secondary, is to be answered 
by a searching inquiry into the state of the stomach. If there be epigastric 
tenderness, and much gastric acidity or flatulence, increased by certain 
articles of food ; if the secretion of bile is defective, and the urine high 
colored ; finally, if the patient be within the dyspeptic period, that is, from 
the sixteenth to the thirty-fourth year, the affection of the stomach is, in 
all probability, primary — that of the head sympathetic and secondary. 

4. In affections of the head the brain often suffers, through both the 
nervous and the vascular systems. In the early stages of a peri- or endo- 
carditis the suffering is chiefly sympathetic ; after that inflammation has 
generated valvular lesions and hypertrophies, the sinister effects on the 
brain are through the circulatory system. Many patients experience head- 
ache, vertigo, sense of fulness, incapacity for mental application, without 
suspecting that the origin of all their sufferings is in the heart. We must 
not be misled by the exclusiveness with which they may direct our atten- 
tiod to the head symptoms, and conclude that they labor under chronic 
inflammation of the brain. In all cases of mild or obscure head disease it 
will be proper to inquire into the condition of the heart by auscultation 
and percussion, without which we cannot be certain of correct diagnosis. 
In some instances there is actual cerebro-meningitis, associated with disease 

■ of the heart, but it is secondary or consequential. 

5. In various parts of our Interior Valley there are periodical hemicra- 
nias, which may be mistaken for encephalic inflammation. The symptoms 



INTERIOR VALLEY OF NORTH AMERICA. 721 

and pathological character of these neuralgias have been ahead} 7 presented.* 
If such an attack occurs in one who resides in what is termed a malarial 
region, and especially one who has lately had an attack of autumnal fever, 
we may, without much hesitation, decide against cerebro-meningitis. But 
where these historical aids to diagnosis do not exist, we must be cautious 
in coming to a conclusion, as so great is the tendency to intermission and 
recurrence in all nervous diseases that some encephalic inflammations have 
closely simulated periodical neuralgia. In a doubtful case the safest deci- 
sion is that which suggests an antiphlogistic treatment. 

6. Mania a potu exhibits many phenomena in common with cerebro- 
meningitis. A frequent pulse, muscular agitations, wildness of the eyes, 
disordered sensation, a peculiar delirium, sleeplessness, and disposition to 
voluntary motion ; yet therapeutic experience has shown that these symp- 
toms do not depend on inflammation, for they are aggravated by an antiph- 
logistic treatment, and cease under the use of opium. Moreover even the 
fatal cases do not show us, in their dissection, either fibrinous or purulent 
secretions. The absence of fever, the maniacal persistence of the delusions, 
the tremulous tongue, above all, the history of the patient's habits, will 
direct us to a correct diagnosis. Nevertheless in the early stages of in- 
temperance, and when the habit has been rapidly established, it cannot be 
doubted that inflammation is sometimes present. I only wish to say that 
it is not a necessary element of this malady. 

VI. Cerebritis. — Pathological researches seem to have demonstrated 
that surface inflammation of the brain may exist without meningeal. If 
so, I presume it does not declare itself by any symptoms different from 
those which indicate cerebro-meningeal or meningeal inflammation; as the 
phenomena presented by the last are chiefly such as result from sympathetic 
or secondary suffering of the gray or vesicular covering of the convolutions. 
The cerebritis we are now considering is deeper seated, and affects the white 
filbrous tissue quite as often as the gray substance of the glanglions of the 
brain. As a general fact, it is more topical and circumscribed than the 
superficial inflammations which have been described, and tends more 
strongly to a suppurative character. When uncomplicated with meningitis, 
the phlogistic symptoms are less acute than in the variety which has been 
described. The pain and fever especially are not so violent, and in some 
cases bear not the least proportion to the impending danger. In some in- 
stances the pain is fixed in a particular spot, in others more diffused, and has 
even been felt in parts of the brain, which were found natural in a post- 
mortem inspection. Delirium is not so early nor so violent as in cerebro- 
meningitis ; but lethargy and coma occur much earlier, and in some cases 
without previous delirium. Another distinguishing characteristic is pain 
and spasm, more or less tetanic, of some muscles, accompanied by paralysis 

* Ante, p. 182-6. 

vol. n. 46 



722 THE PRINCIPAL DISEASES OF THE 

of others. Some of these muscular lesions closely resemble those produced 
by slow empoisoning with the preparations of lead. General convulsions 
sometimes occur, and both hemiplegia and paraplegia are common. Ac- 
cording to the seat of the inflammation the lesions of sensation and motion 
are of course various. When the inflammation is intense, and of consider- 
able extent, it may prove fatal in a few days ; but more frequently it con- 
tinues for weeks and even months. 

Even in the early periods of this inflammation the patient may die apo- 
plectic, or become permanently hemiplegic. The concourse of symptoms 
which characterize the third and last stages of fatal cerebro-meningitis are 
not often present in the closing stage of cerebritis, but are represented by 
apoplectic coma, convulsions and palsies. In some cases, presenting cerebral 
abscess after death, the patient was unconscious of any disease till stricken 
down with fatal apoplexy. 

VII. Secondary Inflammations of the Brain and its Membranes. 
— These commonly take on the form of cerebro-meningitis, but in some 
cases of duramatritis, in others of cerebritis. I do not use the term secon- 
dary in contradistinction to primary inflammation, so much as to antecedent 
fever. When speaking of autumnal remittent fever,* this subject was pre- 
sented, and it recurred upon us in treating of the typhous and eruptive 
fevers, especially erysipelas. In all the cases I have seen, the symptoms were 
substantially the same as in primary cerebro-meningitis, though more or less 
modified by the character of the fever and the reduced condition of the pa- 
tient, at the onset of the inflammation. This modification has much less 
bearing on diagnosis than therapeutics. It is seldom so great as to render 
the former difficult, but in many instances imposes great restriction on the 
use of those antiphlogistic measures which are so indispensable in primary 
inflammation of the encephalon. 



SECTION III. 

PATHOLOGY AND PATHOLOGICAL LESIONS. 

I. Several experimental or speculative replies have been given to the 
question whether, from the anatomy of the head, there can be more blood 
in the brain at one time than another. My own experiments look to the 
conclusion that there can ) and that what may be called a general conges- 
tion of the brain is a reality. If this were not the case, that organ would 
stand as an exception to the others, which require, receive and transmit 
more blood while in a state of functional orgasm than when quiescent. 
But it does not follow that, in every case of encephalic inflammation, the 
whole organ is in a state of hyperemia. On the contrary, that condition 
like general plethora, has not perhaps any special tendency to the production 
of inflammation. It is more likely to eventuate in apoplexy without extra- 

* Vol. II. p. 182. 



INTERIOR VALLEY OF NORTH AMERICA. 723 

vasation. Inflammation is essentially local, and has its centre. It never per- 
vades the whole of any large organ. No one has ever seen the entire brain 
with its meninges in that condition. There might then be fatal inflamma- 
tion within the cranium without its containing more blood than in health. 
Some portion only might be in a state of hyperemia, while other portions, 
by the pressure of the swollen part might be anaemic. In every case of in- 
flammation, there is, however, more arterial than venous blood, and it is the 
former which constitutes the inflammatory swelling as far as it depends on 
vascular turgescence. The modus operandi of the causes which bring about 
this condition presents some variety. First* An excited state of the ner- 
vous system of any part, causes arterial blood to accumulate in its capilla- 
ries. The brain is the largest mass of that system, and cannot be excited 
without thus reacting on the circulation. In this manner, excessive mental 
effort and sudden or powerful emotions may be followed by inflammation. 
The hyperemia in these cases is not always, perhaps not often seated in the 
cerebral pulp; but established in the vascular membrane through which the 
former receives its supply, and on which it manifestly has a power of action- 
Second. In concussions from blows or falls, some portion of the organ re- 
mains enfeebled in its circulation longer than the rest, and when reaction 
takes place, its capillaries become injected, and the phenomena of inflam- 
mation arise. Third. In vicissitudes of temperature, in the sudden libra- 
tions of the circulation from the exterior to the interior parts of the body, 
some portion of the brain or its membranes become engorged, and inflam- 
mation follows. Fourth. It is a physiological law that the excitation of the 
stomach by stimulating food and drinks, should excite the brain, and dis- 
turb its circulation. More blood appears to flow to it in a given time — per- 
haps less is transmitted through it, and thereby a state of capillary hyper- 
emia is induced in some part, which results in inflammation, a condition 
more likely to arise if the lower bowels be torpid and do not make their ordi- 
nary physiological revulsion from the brain. Fifth. The hypertrophied 
heart injects too much arterial blood, with too much force, into the brain. 
The distended arteries compress the veins which in some portion of the 
organ may not carry off the excessive supply, and thus a capillary hypere- 
mia may be established. Sixth. Some inflammations, as the rheumatic, are 
attended with a constitutional diathesis which causes the successive develop- 
ment of inflammation in all the fibrous structures, and may thereby attack 
the dura mater. Others, like erysipelas, travel by continuity of texture, 
and may reach the brain from the integuments of the scalp. Seventh. In 
various fevers, the perverted state of the vital properties and the visceral 
congestions so common in the whole, generate inflammations, some of which 
are found in the brain. 

II. The fever attendant on encephalic inflammation, is, cceferis paribus, 
more acute in meningitis and cerebro-meningitis, than when the local affec- 
tion is seated exclusively in the pulpy substance. In some cases the fever 






724 THE PRINCIPAL DISEASES OF THE 

seems to precede the inflammation; in some to follow it ; in others to arise 
simultaneously with it. They act and react on each other, and generally 
subside together. When the inflammation is mild the fever is correspond- 
ingly slight, and when both mild and limited in extent, may be altogether 
absent. In true cerebritis, this is often the case ; and hence a fatal dis- 
organization of the brain may be brought about without febrile disturbance 
of the organism generally. We have already seen that during this phlogistic 
fever many disturbances of function occur that are in some degree peculiar. 
They are often spoken of as sympathies with the brain ; but it would be 
more correct to refer them to the influence which the brain exerts over the 
organism. This influence in health is exerted according to physiological 
laws, but when the organ is inflamed, its influence is either withheld or 
imparted in a pathological manner, thus carrying disorder into the functions 
over which it had presided in health. Among these disturbances of func- 
tion we may enumerate the irregularities of the heart's action, sometimes 
much diminished by a copious bleeding which relieves the brain from con- 
gestion ; the various morbid states of sensation and of the muscles of loco- 
motion, are referable to the same cerebral infirmity, oppression, or pertur- 
bation. 

III. Both the inflammation and the fever may greatly abate, and yet 
recovery not take place; nor is there in all cases an absence of morbid phe- 
nomena. The diseased actions which gave rise to the inflammatory and 
febrile symptoms, gradually produced lesions of secretions, with other dis- 
organizations, which remain after the actions cease, and declare themselves 
by what constitute the symptoms of the last stage of fatal cases. If slight, 
they may be repaired ; but in the majority of cases, permanent infirmity or 
death follows on this crippled condition of the organ, and this brings us to 
an enumeration of the forms of pathological change found after death. 

IV. Pathological Anatomy. — 1. One of the most constant appearances 
found after death from supposed meningitis or cerebro-meningitis, is serum 
effused beneath the arachnoid and into the ventricles. When this exists 
alone, the question arises whether anything more than simple congestion 
had existed ? That it may be the consequence of such congestion cannot, I 
think, be doubted ; but if symptoms of phlogistic excitement however mild 
existed during life, I should be disposed to believe there had been inflam- 
mation, although neither lymph nor pus might be present. But waiving 
this question, it may be affirmed that the serous accumulations play an im- 
portant part in the production of the phenomena of the final stage, and in 
rendering it incurable. To them we must chiefly ascribe the compression 
of the brain, and the insensibility and paralysis which precede dissolution. 
2. Fibrinous effusions leave no doubt as to the existence of inflammation, 
and they are generally associated with patches of hyperaemia. Should the 
latter be present without fibrinous secretion, the same conclusion might be 
drawn. The fibrinous exudation sometimes exists in the serum in such 



INTERIOR VALLEY OF NORTH AMERICA. 725 

quantities as to render it turbid. In other cases the quantity of serum is 
very small, and the fibrine is chiefly found in deposits underneath the arach- 
noid, rendering that membrane opaque. This is the characteristic lesion of 
cerebro-meningitis; especially when acute and rapid. When mild, its pro- 
portion to the serum is much less. When the inflammation, as sometimes 
happens attacks the sinuses of the brain, they become plugged up in part 
by the fibrine of the secreted coagulating lymph, and in part by the fibrine 
of the arrested venous blood. 

In certain limited and chronic inflammations of the cerebral substance, 
the part is found in a state of induration. This is the result of the effusion 
and organization of lymph. Such a condition slowly produced may not be 
incompatible with life, and is often found after death from other diseases, 
the cerebritis having been cured, or ceasing spontaneously. Pus is not 
often found on the membranes of the brain, but is more common than lymph 
in the cerebral substance, both gray and white. Sometimes it is encysted, 
at other times diffused, and mixed with the broken down cerebral substance. 
The two elements are distinguishable by the microscope. This is one of 
the forms of softening. Another presents the same kind of disorganization 
without the purulent secretion. A free secretion of serum probably contri- 
butes to this softening. In some cases these lesions of the brain seem to 
be produced suddenly, in others slowly. As they are sometimes found in 
individuals who have died without previous signs of cerebral disease, it is 
possible that the cases of apparently sudden softening have been of long 
standing, and the fatal cerebritis but an aggravation of a mild and insidious 
inflammation. Of softening not dependent on that pathological condition, 
this is not the place to speak. 

SECTION IV. 

PREVENTION AND CURE OF CEREBRO-MENINGITIS. 

I. Prevention. — The difficulty of arresting this inflammation, greatly 
augments the value of prophylaxis. An abatement in mental application, 
may often arrest the disease in its forming stage. Wearing the hair short, 
wetting the head night and morning, and lying with it raised, are not un- 
important measures. Where there is a manifest tendency to the disease, an 
abridgment of diet and total abstinence from alcohol and all narcotic stimu- 
lants are indispensable. The feet should be bathed at night, and kept warm 
at all times, so as by revulsion to counteract the tendency to cerebral con- 
gestion. If an ulcer or chronic inflammation of any kind, on beginning to 
heal or abate, should be followed by signs of encephalic inflammation, a 
blister should be applied over the affected part. But in all cases the pre- 
servation of an open habit of body, and even free purging, may be regarded 
as the most important preventive. The blue mass and aloes alternated with 
Epsom salt are the best aperients, as they act on the liver, the mucous mem- 



726 THE PRINCIPAL DISEASES OF THE 

brane of the small intestines, and on the rectum, the irritation and free 
evacuation of which contributes greatly to revulsion from the brain. Under 
this treatment, the system may become irritable especially when simple con- 
gestion, with but little tendency to hyperinoses of the blood, has constituted 
the pathological condition. To avert such a result, active exercise in the 
open air, avoiding exposure to the hot sun, should be recommended. The 
blood will thus be invited into the spinal cord and muscles of locomotion, 
and while constitutional irritation is warded off, revulsion from the brain 
will be promoted. 

II. Treatment. — The treatment of acute and violent cerebro-meningitis 
should commence early, or fatal disorganizations will take place. The cure 
of milder cases is effected by the same agencies used in severer, employed 
in a more limited extent. 

1. In no disease is regimen of greater moment. Having made a reliable 
diagnosis, the hair of the patient should be immediately cut close with scis- 
sors, and the scalp washed for some time with tepid water. His feet should at 
the same time be immersed in warmer water, and rubbed to redness. His 
bed should not be of feathers, and his pillows not so soft as to bury up his 
head, and should be so numerous as to raise the upper portion of the trunk 
above the ordinary angle. The head of his bedstead should be on the side 
of the chamber through which the light is admitted, and the wall on which 
his eyes rest, should be of one color. The admitted light should be broad 
and diffused, but not greater than is required for the purposes of the 
nurse and physician. The air should not be shut out in warm and mild 
weather; and in the winter the radiant heat of the fire or stove should not 
be allowed to strike on his head, nor should the temperature of the cham- 
ber be raised higher than may be necessary to the comfort of the atten- 
dants. The light of lamps or candles should not be allowed to fall on his 
eyes. All noises should be abated in and around his apartment, and all 
persons excluded but those who wait upon him, whose conversation, however, 
should not be in whispers, but loud enough to be distinctly heard by him, 
otherwise he will be making constant efforts to ascertain what is said. Every 
kind of diet should be withheld ; cold or subtepid drinks may be freely per- 
mitted. The sponging of his head with tepid water ought to be continued 
regularly. I am aware that the common practice is to apply ice or ice-water 
to the scalp, and do not condemn it. But as the external heat of the head 
can soon be brought below the standard of health, by subtepid sponging or 
laving, if measures be taken to promote evaporation, and as water of that 
temperature exerts a soothing influence on the nervous system, I have very 
commonly preferred it to applications of icy-coldness. Measures fitted to 
raise and preserve the heat of the feet and legs, should be diligently em- 
ployed. 

When we recollect the relations which the brain bears to the organs of sense, 
including the skin and stomach, we see at once the indispensable necessity of ex- 



INTERIOR VALLEY OF NORTH AMERICA. 727 

eluding as far as possible every agent capable of exciting them, and my own 
experience assures me, that this regimen is of equal value with all the 
other measures of cure. 

2. Arrangements having been made for placing the patient in bed, he 
should sit upon it and be bled till manifest signs of approaching syncope 
appear, when he should be laid down. To produce this effect, the loss of 
sixteen, thirty-two, or even forty-eight ounces may be necessary. Such a 
bleeding will in many cases be sufficient, but in a greater number the opera- 
tion must be repeated. A third, and in rare instances a fourth may be re- 
quired ; but none of them should be as copious as the first, except when 
that is employed in the forming stage, at which time syncope may occur 
from a small bleeding. Too ready a resort to cups and leeches must be 
avoided ; but when we are in doubt about the further use of the lancet they 
may be substituted for it. 

3. The next remedy in time and value is purging. As soon as the patient 
has recovered from his tendency to fainting, an active cathartic should be 
given. From ten to twenty grains of calomel, to be followed by Epsom 
salt in senna tea, may be administered, or ten grains of jalap and ten of 
calomel. The object is not merely to evacuate the existing contents of the 
stomach and bowels ) but to promote free secretion from both the liver and 
the intestines, whereby a most salutary revulsion from the brain is effected. 
Throughout the whole course of the disease, the bowels should be kept in 
an open and secreting state. When the first cathartic does not operate in 
due time, an enema would seem proper. Such tardiness, however, shows 
that the loss of blood had not been great enough, and a return to the lancet 
will generally bring on the operation of the medicines better than a resort 
to the syringe. 

4. After the effects of the first cathartic are over, the exhibition of calo- 
mel should be commenced in two, three, or four grain doses, every six or 
eight hours, and continued until the abatement of the disease is manifest. 
Of all the antiphlogistic alterants it is the best in this inflammation, the 
arrest of which cannot safely be confided to depletives and revulsives. 

5. Of the value of epispastic irritation in this disease, I am less assured, 
than of that irritative secretory action which is produced by purgatives. In 
observing the rule not to apply them till the phlogistic excitement is re- 
duced to a certain undefined grade, they are often postponed too long. To 
make a metastatic transfer of the inflammation, they should be applied 
while it is yet in the forming stage. If the first bleeding and the first purging 
have been what they should be, large blisters may be applied to the legs or 
to the nucha immediately after their employment. The next application 
should be to the scalp of one side of the head — the last to the other side. 
The practice of deferring this application to an advanced stage of the dis- 
ease has nothing to sustain it; I have not then found it useful, and it is 
generally opposed by the friends, who might have consented to it at an 
earlier period. 



728 THE PRINCIPAL DISEASES OF THE 

6. Beyond these few and simple measures, but little, I apprehend, can 
be done to resolve a meningitic inflammation. Under their influence, 
the disease often yields kindly, and early signs of convalescence appear. 
But there are cases in which such signs do not show themselves, pari passu, 
with the decline of phlogistic symptoms, and in their place we have the 
phenomena of constitutional irritation and exhaustion. The movements of 
the heart are frequent, quick, convulsive, and loud ; the skin, variable in 
temperature, does not resume its natural functions ; the mouth is dry, and 
the tongue shows a brownish hue; more or less subsultus tendinum and 
restlessness occur; the mind is capricious and unsettled, or there is full de- 
lirium, and, with occasional soporose periods, there is general watchfulness, 
with contracted pupils, and a staring and anxious expression of the eyes. 
The physician is often at a loss as to the import of this group of symptoms, 
and uncertain whether they declare increasing inflammation or a state of 
exhaustion and morbid sensibility, produced in part by great depletion, and 
in part by the seat of the inflammation being the brain. Cases presenting 
all the symptoms of nervous irritation here enumerated, are, it is true, suffi- 
ciently marked ; but many fall short of the whole, especially in the first or 
developing stages of this pathological condition. Having decided on its 
existence, all depleting and counter-irritating treatment must be discontinued 
for one that will sustain the sinking energies, and allay the morbid sensi- 
bility of the nervous system. Moderate quantities of gelatinous and amy- 
laceous food should be administered with wine whey or weak spirits and 
water. Of medicines, Dover's powder, in broken doses, a syrup of morphia, 
with wine of ipecac, or a solution of carbonate of ammonia with paregoric, 
and one of the salts of morphia, is the best, and should be administered at 
short intervals, till composure and sleep are produced. If cold applications 
to the head had made a part of the previous treatment, they should be dis- 
continued ; the feet must be kept warm ; and under the influence of a weak 
infusion of serpentaria, eupatorium, or sassafras, a general diaphoresis, or 
actual perspiration should be brought on, and if possible kept up. Should 
the patient live in what is called a malarial region, it may further be advis- 
able to combine a portion of sulphate of quinine with the medicines which have 
been named, as many of the phlegmasiae, in such localities, show, after great 
depletion, the impress of the cause of autumnal fever. A simpler method, 
which is sometimes signally successful, is the administration of a large dose 
of laudanum, Dover's powder, or one of the salts of morphia — a dose that 
would equal in its narcotic effects, two, three, or even four grains of solid 
opium, — a good practice when the diagnosis is correct; but injurious, should 
the symptoms depend on inflammation. 

If the patient be not relieved by this treatment, the prognosis of the case 
is fatal. Inflammation is still lingering in some part of the brain, while 
the powers of the system are becoming exhausted, or serous effusion is going 
on to the production of mortal compression, and this brings us to the treat- 
ment of the final stage. 



INTERIOR VALLEY OF NORTH AMERICA. 729 

7. I have made and read the history of a number of post-mortem exami- 
nations, in which the appreciable anatomical lesions seemed insufficient to 
account for the death of the patient. In such cases it is, I presume, tbe conse- 
quence of the lesion of cerebral function, which has just been described, aided, 
no doubt, by whatever anatomical derangement may exist. In other, and the 
majority of fatal cases, the exhaustion from excess of action in the brain still 
being present, the lesions are extensive, and seem to play the most important 
part in the production of a fatal result. Xow it is that we have symptoms of 
compression, and sinking energy. Coma and muttering delirium ; a dry and 
dark tongue which the patient cannot protrude; dilated pupil; strabismus; 
feeble and intermittent pulse; subsultus; spasms and paralysis, as enume- 
rated in the preceding section. When a majority of these symptoms are 
present, recovery, if not impossible, should never be predicted or expected. 
But what can be done to remove congestion, arrest serous, sero-fibrinous or 
purulent secretion, promote absorption, put a stop to softening, and pre- 
vent the rapid sinking of the vital powers ? I have tried, and seen tried by 
others, many things, but have no evidence that they have ever been suc- 
cessful. Internal stimulation ; the internal and external use of mercurial 
applications in large quantities, with the view of exciting a salivation ; a 
blister over the whole scalp, and sinapisms to the lower extremities, or the 
application to the latter of scalding water, have but too often failed to pro- 
duce any effect. Yet it is not necessary to condemn their use ; for the in- 
sensibility of the patient, which in general precludes their doing good, at 
the same time defends him from any suffering from their employment. 
"When he does manifest suffering, his case is less desperate, and they may 
then be of service. 

III. Treatment of Cerebritis. — When our diagnosis excludes menin- 
gitis, and places the inflammation in the cerebral substance exclusively, are 
we to employ a different or the same treatment which has been recommended 
for meningitis or cerebro-meningitis? The treatment should be substan- 
tially the same ; but in general the inflammation is more circumscribed and 
its manifestations less acute. Still further, there is much reason for be- 
lieving that it forms and advances in a more insidious manner, and is often 
tending to suppuration or the destruction of the cerebral substance by soft- 
ening before the physician is called in, or at least is fully aware of the true 
condition of his patient. It must be granted that under such circumstances 
the antiphlogistic treatment is the only one which can be employed with 
any prospect of success; but it cannot be carried so far as in cases of cerebro- 
meningitis, and high hopes of its success should not be cherished. That 
treatment is directed against a phlogistic diathesis, and the system is tole- 
rant of it in proportion as the diathesis is intense. But in cerebritis, in- 
ternal and local, there may not be great inflammatory excitement, and yet 
a fatal, though perhaps very limited disorganization of the brain may be 
going on. 



730 THE PRINCIPAL DISEASES OF THE 

The seat of the disease is the great source of danger, and we have examples 
of the same kind in iritis, valvular endocarditis, and cedematous laryngitis, 
which, unaccompanied as they often are, by a general phlogistic diathesis, 
will to our surprise, survive copious depletion ; and from the peculiar func- 
tions of the organs in which they are seated, produce permanent infirmity or 
speedy death. It is when the inflamed part and the general system harmonise, 
so to speak, in their diathesis that general antiphlogistic treatment shows 
its greatest power; and hence it is sometimes easier to subdue an extensive 
or very violent inflammation, than one more limited or less intense. In 
children it is easier to arrest a wide-spreading meningitis of the convolutions 
than an inflammation limited to the lining membrane of one of the ven- 
tricles. 

But if in many cases of cerebritis uncomplicated with meningitis, we 
derive less aid from copious bleeding, we may administer calomel freely, 
for its alterant effects; and if cold or subtepid applications to the head are 
of less value, counter-irritation is perhaps more, and cathartics of equal 
utility. 

When suppuration, softening, and ventricular effusion, or either of them 
has taken place, it remains to be shown, that any treatment can be success- 
ful; for in every supposed case of recovery, it is uncertain whether, in fact, 
those lesions had occurred. 

IV. Treatment of Chronic Encephalitis. — As autopsic examina- 
tions have shown the ravages of encephalic inflammation, though no fever 
nor received diagnostic signs of that affection had occurred during life, we 
may well believe that we have under this head many cases which no skill 
in symptomatology can with certainty refer either to inflammation, neuralgic 
irritation, simple congestion, or sympathy; and, therefore, many cases of 
chronic encephalitis are overlooked, and many non -inflammatory affections 
treated as if they were chronic encephalitis. It would be difficult, I think, 
to find any other field of diagnosis as unsatisfactory and uncertain as this. 
A safe practical rule in all doubtful cases is to class them with the inflam- 
mations ; for if they should not be such, the antiphlogistic treatment, unless 
persevered in, will do no harm, may even be of much preparatory value ; 
while on the other hand, should inflammation exist, it would be increased 
and prolonged by stimulants, tonics, and narcotics. 

In the treatment of this affection, a single copious bloodletting will seldom 
do harm in any case, and proves beneficial in many. After that, leeching 
and cupping will be sufficient as far as the loss of blood is concerned. 
Purging for a time, and gentle aperients afterwards will be proper. A mild 
and long-continued mercurial course, consisting of a grain of calomel morn- 
ing and evening, is frequently of excellent effect. Blisters to the nucha, 
followed by a free sero-purulent discharge under the use of stimulating 
dressings are proper. Irritating foot-baths, and every means of maintain- 
ing the heat and circulation of the lower extremities, are important. A 



INTERIOR VALLEY OF NORTH AMERICA. 731 

reduced diet persevered in is indispensable ; and all alcoholic stimulation 
should be avoided. Finally, every cause of mental excitation, and all severe 
labor of mind should be avoided. 

An Illustrative Case. — It is probable that chronic encephalitis is 
connected with many lesions of sensation, motion, and even organic func- 
tion, which have received nosological designations that do not fasten the 
mind upon that pathological condition, but lead it in an opposite direction. 
These designations are vertigo, congestion of the brain, amaurosis, deafness, 
loss of smell, local spasm, and local palsy, epilepsy, hemiplegia, neuralgia, 
hydrocephalus chronicus, dyspepsia, and disease of the heart. Most of 
these terms do indeed direct our attention more or less to the brain, but not 
to inflammatory action in that organ, and some of them not even to simple 
congestion. As illustrating the pathological connection, c temporary or 
consecutive, which may exist among them, I present the following case 
which occurred many years since in my own practice, and was published 
more circumstantially in 1827.* 

"On the 24th of May, 1824, I was requested to visit Mr. J. R. W., of 
Cincinnati, aged about forty years, who had for several months been confined 
to his house with neuralgia of the left side of his head and face. "The his- 
tory of his case, as compiled from the statements of himself, his family, and 
one of his attending physicians, is as follows : — 

" His father, and some of his brothers had been subject to gout. For 
many years he led a seafaring life as supercargo of a trading vessel, and 
afterwards resided in one of our eastern cities as a merchant. He was always 
temperate in drinking; and not intemperate in eating, though he had a 
strong appetite, which he had not particularly restrained, and could eat, 
without acidity or flatulence, many things which are apt, in ordinary sto- 
machs, to produce those symptoms. He had been generally subject to consti- 
patio infest inalis ; but up to his thirty-fourth year his health was good, and 
his constitution seemed unimpaired. About this time (December, 1819), 
being in high health, he was suddenly affected, in one of the streets of Phi- 
ladelphia, with general debility of his left side. After leaning against a 
pillar of the market-house for a few minutes, he recovered, and proceeded 
to his place of destination, the court-house ; where, in a short time, the 
hemiplegia returned. A physician being called in, he was bled copiously, 
and then carried home. Five or six successive bleedings, with the liberal 
administration of cathartic medicines, so far relieved him, that in ten days 
he was able to serve as a juryman, in a case for which he had been selected 
before his attack. After serving two days in this capacity, he was seized 
with a violent headache, for which he was cupped with advantage. Three 
days afterwards, when confined in a close and hot jury-room, the atmosphere 
of which was loaded with tobacco smoke, the paralysis returned, but was 

* Western Medical and Physical Journal (Cincinnati), vol. i. p. 11. 



732 THE PRINCIPAL DISEASES OE THE 

arrested by another bloodletting, performed on the spot by one of the jury. 
He was then taken home a second time, where he slowly recovered ; and 
through the ensuing spring, summer, and autumn, enjoyed good health. In 
October (1820), he visited the western country, where he spent the winter, 
in his usual health, and started home in the spring of 1821. On his way 
back, he had an attack of catarrh. Soon after his arrival in Philadelphia, 
he discovered that his sense of hearing in the left ear was much impaired; 
and it continued so till the month of January, 1824, when it began to im- 
prove ; and by the spring of that year was nearly restored. 

" About the time that he first experienced this deafness, he observed his 
sense of smelling, in both nostrils, to be obtuse. It gradually became ex- 
tinct; and the Schneiderian membrane, at the same time, fell into a state of 
deficient secretion, which still continues. In the month of September, 
1821, he emigrated to Cincinnati. During this autumn he had two attacks 
of sore throat (cynanche pharyngeal), neither of them attended with ulcera- 
tion. In the following winter, a hard, indolent, and insensible tumor ap- 
peared between the angle of his mouth and his ear, within the limits of the 
left whisker. The skin was not discolored, but it suppurated slowly, and 
was regarded as scrofulous. In the succeeding summer he drank, for some 
time, a decoction of speedwell, and the ulcer slowly healed up. In August, 
he had an attack of dysenteric fever. In December, when in tolerable 
health, and pursuing his ordinary business, he again suddenly suffered a 
loss of power in his whole left side, with feelings similar to those attendant 
on the hemiplegia of 1819. He was immediately bled, and got better. 
His health for the remainder of the winter was good. In the month of 
February, 1823, he set off for Philadelphia, and returned in March. On 
his way back, he had ( a bilious attack/ which left him weak and disor- 
dered, for which he was directed to take a bitter infusion. This he conti- 
nued through the months of April and May, within which period he lost a 
child, and became much depressed in spirits. 

" The disease for which I was consulted now began to show itself. The 
first pain which he experienced, was chiefly in the back part of his head. 
At length his left eye became weak, watery, and somewhat red, with slight 
pain and swelling. In June he visited Philadelphia, and the disorders of 
his head and eye continuing, with signs of general debility, he was advised 
by a distinguished medical gentleman to use tonics, a nourishing diet, and 
sea-bathing. He adopted the two former ; but, resolving to return to Cin- 
cinnati, omitted the last. Before leaving the city, he was cupped to the 
quantity of eight ounces, from which, however, he seemed to receive no 
benefit. The pain continued, and by autumn had established itself in the 
forehead, temple, and cheek of the left side. At first it appeared chiefly in 
the evening, in the form of an excruciating paroxysm; but at length it lost 
the periodical character, and becoming more constant, was rather less pun- 
gent. From this period to the time when I saw him, his sufferings had been 



INTERIOR VALLEY OF NORTH AMERICA. 733 

nearly incessant. In the month of January, 1824, after experiencing aggra- 
vated pain, from the application of caustic to his temple, in the day, he was 
seized, soon after lying down at night, with an epileptic fit, preceded by a 
scream, attended with frothing at the mouth, and followed by deep stupor 
till midnight. On the 16th of the following May, a week before my first 
visit, when sitting up in the forenoon, comparatively free from pain, and 
conversing with a friend, his face was observed to flush, and became sud- 
denly covered with sweat. He, at the same time, complained of feeling 
bad, and was laid on the bed, where he had three epileptic convulsions, 
attended with the same symptoms as before. 

" When I saw him, a week after this event, his situation, he thought, was 
not materially different from what it had been for the preceding six months. 
He had several exacerbations of pain in the twenty-four hours, some of 
which were intensely severe. They recurred at no regular periods. In the 
remissions, the affected parts, from the upper region of the forehead to his 
mouth, became the seat of a great variety of indescribable sensations ; such 
as might be supposed to arise from the puncture of the slenderest need'e ; 
from minute insects crawling in the skin; or from the passage of a fluid 
through the apertures of the subcutaneous cellular membrane. The first 
kind of sensation was generally between the upper lip and the eye; the last 
more commonly in the forehead and temple. None of these feelings were of 
a pleasurable kind. The whole left side of the face and forehead were often 
perceptibly tumefied, and sometimes slightly cedematous. That side of the 
forehead, and the eye, were often red — the former exhibiting a circumscribed 
flush. The sense of taste, in the left side of his tongue, and the natural 
feeling of his mouth and teeth, of the same side, were much impaired. But 
none of his teeth were tender or decayed. The left angle of the mouth 
hung a little, while the other was slightly retracted. The pain was gene- 
rally aggravated by a recumbent position. He was never chilly ; but often 
had flushes of heat in the evening. His tongue was red, and slightly furred. 
His pulse was variable, fluctuating from eighty to one hundred beats a 
minute, and not remarkable for force or fulness. He was able to walk about 
his room. His memory was much impaired, and his temper irritable." 

Here then was or had existed moderate hemiplegia of the left side, par- 
tial deafness of the left ear, impairment of taste in the left side of the 
tongue, total loss of smell in both nostrils, epilepsy, failure of memory, 
irascibility of mind, and lastly, intense neuralgia of the first and second 
branches of the fifth pair of nerves of the left side, with congestion and 
oedema of the loose texture of the eye and the surrounding parts. 

To this neuralgic affection the attention of the patient and his physicians 
had been chiefly directed, and, 

"Within the preceding eight months he had been subjected to the fol- 
lowing plans of treatment : — 



734 THE PRINCIPAL DISEASES OF THE 

" 1. A long-continued course of moderate purging, chiefly with mercurial 
medicines, from which some advantage appeared to result. 

" 2 . A course of tonics consisting of rubigo, ferri, the hark, and the sul- 
phate of quinia, all given in large doses, with various adjuvants, but to no 
good end. 

" 3. A narcotic course ; during which the prussic acid, cicuta, stramonium, 
and belladonna, were all given, until they produced their specific morbid 
effects upon the system ; but they seemed rather to increase than mitigate 
his sufferings. 

"4. A short course of arsenic, which was thought to be injurious. 

u 5. A gentle mercuiial course, which seemed to be useful. 

" 6. Palliatives, antidyspeptics, and antispasmodics; such as great quan- 
tities of opium, in different forms ; a tincture of colomba and gentian, with 
aromatics ; the tincture of mur. ferri, and a mixture of the tinctures of assa- 
foetida, valerian, guaiacum, and castor, with ammoniated alcohol and lau- 
danum. 

" 7. Unceasing topical applications, consisting chiefly of blisters, issues, 
electricity, and a great variety of stimulating and anodyne embrocations. 

" 8. The general warm bath with frictions, and as much exercise as 
possible. 

u 9. A nutritious diet, embracing, and indeed almost composed of animal 
food, rendered stimulating by the consumption of two quarts of French 
brandy every week." 

On reviewing the history of the symptoms and treatment of this case, I 
would not hesitate, in deciding on the existence of chronic inflammation 
within the cavity of the cranium,, and in recommending an antiphlogistic 
method, consisting of venesection and cupping, purging, a reduction of diet, 
and an abandonment of all stimulants, tonics, and narcotics. The patient, 
who had been taught by his physician, that his disease was nervous, and 
that he would sink if those remedies were laid aside, and all the sooner, if de- 
pletions should be substituted, at first refused ; but in a day or two consented, 
and a new treatment was adopted. It is not necessary to the end I now 
have in view to give the details of daily treatment for the next three weeks, 
when it was laid aside, as a general statement with the results will be 
sufficient. 

The first bleeding was purposely limited to six ounces. The blood was 
sizy and cupped. Its loss produced no effect on his pulse. In two days he 
was bled again to eight ounces. Blood buffed. In three days he was cupped 
to four ounces. In two days bled to half a pint, the clot sizy and cupped; 
in two more, bled to fourteen ounces, clot the same j four days afterwards, 
lost ten ounces, appearances not noted ; after the lapse of an equal period, lost 
sixteen ounces, inflammatory crust thicker than before ; at the end of three 
days lost eighteen ounces, which was less sizy and cupped than the last; in four 
days lost fourteen ounces, still less inflammatory. This was the last bleed- 



INTERIOR VALLEY OF NORTH AMERICA. 735 

ing. In three weeks he lost ninety-eight ounces ; and was yet much stronger 
at the end than during the use of stimulants; notwithstanding other, so- 
called, debilitating measures had been employed throughout. These were 
tartarized antimony in minute doses, calomel to the extent of a slight sali- 
vation ; the same medicines combined with jalap and nitre, as a cathartic ; the 
first dissolved in a solution of sulphate of magnesia, for the same purpose ; oleum 
ricini, and in the latter periods, salino-sulphurous water, a sedative aperient. 
At different times during the treatment, a state of nervous irritability was 
quieted with spiritus Mindereri and paregoric, Dover's powder, and assa- 
fcetida pills. When the active treatment was discontinued, at the time just 
mentioned, his pulse which ranged from ninety to a hundred in the begin- 
ning, had fallen to seventy-two. His physiognomy had become natural, 
and he felt better than he had done in ten months. Five days after the 
last bleeding he rode two miles in a gig, and returned hungry and sleepy. 
From this time he took no medicine except the sulphur water; rode 
daily, and was soon able, on foot, to visit his counting room. A more 
generous, but still an abstemious diet was ordered. He slept well. Occa- 
sionally in the evening, he had some ©edematous fulness of the left side of 
the face; but in the morning and through the day, its appearance was the 
same with the right side. He ceased to have any pain, and suffered but 
little from the sense of motion in the parts which had so long distressed him. 
His pulse remained variable and easily excited. His spirits became buoyant, 
and his friends thought him more animated and conversational than he had 
been since the attack of palsy in 1819. 



CHAPTER VIII. 

INFLAMMATION OF THE NERVOUS CENTRES CONTINUED: TUBERCULAR 
ENCEPHALITIS — HYDROCEPHALUS. 

I. In contemplating the diseases of children and adults we are not 
always quite consistent. Thus we do not distinguish the pneumonias or 
dysenteries of one age from those of another, while we speak of cholera 
infantum and cholera morbus, and give to encephalitis the name of hydro- 
cephalus acutus when it occurs in children. This diversity of nomencla- 
ture for the same malady, according as it appears in childhood or adult life, 
is well fitted to mislead us by suggesting diversity of pathological condition, 
when none in reality exists. In the disease we are now studying, however, there 
is some foundation for the use of different terms, though not for those which 
are commonly employed. The quantity of serum ordinarily found in the 
ventricles of the brain after death from the acute encephalit s of children, 
is not such as to justify its classification with the true dropsies of the brain, 
resulting from increased secretion into the ventricles, without inflammation, 



736 THE PRINCIPAL DISEASES OP THE 

and is often not greater than we find it in adults ; yet we continue to em- 
ploy the term hydrocephalus, or its vernacular synonyme (dropsy of the 
brain), and limit its application to the encephalitis of children ; thus con- 
structing varieties on false data. 

If we at all distinguish the encephalitis of children from that of adults, 
it cannot be by its seat or products of secretion, but by the effects of a pre- 
existing diathesis — the tubercular, as suggested by the title of this section. 
That diathesis, it is true, is not peculiar to childhood, nor is tubercular en- 
cephalitis confined to that stage of life. But the tendency to tuberculiza- 
tion of the brain is greater in childhood — of the lungs in manhood ; and 
hence while tubercular pneumonitis is more frequent in the latter, tuber- 
cular encephalitis is more common in the former stage of life. According 
to these views, encephalitis, whether in the young or the more aged, is 
either simple or tubercular, and each variety may theoretically be divided 
into meningeal and cerebral, according to the seat of the inflammation. In 
simple encephalitis, as we have already seen, this division is difficult in 
practice, and of little value ; in the tubercular it is perhaps still more diffi- 
cult and even of less importance. It is not unimportant, however, to ascertain 
the type of the disease, for in the simple the system is more tolerant of 
antiphlogistics, and the prognosis may be more favorable than in the tuber- 
cular. I know of no data for determining the relative frequency of these 
two varieties; for although extreme cases of each may differ widely, the 
intermediate present no definite line of distinction, as the tubercular dia- 
thesis may exist in various degrees. Even the results of treatment do not 
reveal it, for a non-tubercular child of lymphatic temperament will not bear 
depletion better than another of a different temperament who might be tu- 
bercular. What has been said on the causes, symptoms, lesions, and treat- 
ment of simple encephalitic inflammation in the preceding sections, although 
pointing directly to adults, is, with little modification, equally applicable to 
children, although the disease when occurring in them receives a different 
name. What I may say in this section will relate, or be intended to relate, 
chiefly to the variety produced by a pre-existing tubercular diathesis. 

II. As anatomy displays the whole structure of the body, but in part only re- 
veals its functions, so pathological anatomy presents the lesions of structure, but 
fails to inform us concerning many of the pathological actions by which those 
lesions are produced, and thus many conditions of the system declare them- 
selves to our observation by their effects only. One of these conditions has 
received the name of tubercular diathesis, and is made the subject of ex- 
amination in the chapter on pulmonary consumption. When inflammation 
of any portion of the brain or its envelopes is set up in a child or in an adult 
with this diathesis or predisposition, we have a case of tubercular encepha- 
litis, or, in other words, of that form of hydrocephalus which an ample ex- 
perience has shown to be generally fatal. It is, I think, undeniable that 
this diathesis gives a predisposition to inflammation, and that children 



INTERIOR VALLEY OF NORTH AMERICA. 737 

having it are more obnoxious to various causes of inflammation than those 
from whom it is absent. Thus it plays a twofold part — inviting that form 
of morbid action, and also rendering it more difficult of cure. With a 
tubercular diathesis this form of inflammation may be developed without 
the agency of any exciting cause, and is then said to arise spontaneously. 
It seems probable, however, that in such cases tubercular deposits have gra- 
dually taken place in the brain or its membranes, and, as in the lungs, irri- 
tate the tissues into inflammation. With its exsanguine condition, rapid 
development, and great activity of function in childhood, a very slight irri- 
tation, primary or secondary, may awaken inflammatory action. The acti- 
vity of which I speak is shown by the incessant voluntary motion of 
children, their rapid and unwearied observation, their speedy acquisition of 
knowledge, and the exceedingly active and efficient performance of the func- 
tions of respiration, circulation, digestion, and assimilation during the period 
of growth, in every one of which the brain plays a more or less important part. 
With this predisposition very slight causes may excite encephalic inflamma- 
tion, but when an occult, congenital proclivity to tubercle pervades the 
constitution, all exciting causes are still more dangerous. Thus falls and 
blows on the head, which in the absence of that constitutional lesion might 
do no harm, may awaken inflammation; and so of gastric repletion, intes- 
tinal, or verminous irritation, sanguineous repletion, improper exposure, 
and inordinate mental exertion, the commonly assigned causes of encephalic 
inflammation. They may generate it in any child, but are more likely to 
kindle it in one having the tubercular diathesis. Of the whole the cause 
which does most injury is mental application, prematurely diverted from the 
natural channel of spontaneous, diversified, out-door observation, to in-door 
book studies, which embarrass the young mind with abstractions, and over- 
work and irritate the brain, whereby its circulation is disturbed, while the 
reduced state of respiration prevents due elimination from the lungs, and 
promotes the tubercular development. As unsound or imperfect fruit ripens 
first, so children of this diathesis often have precocity of mental and moral 
development, which leads them to studies not appropriate to childhood, and 
fatally misleads parents as to the discipline which should be exercised over 
them as a means of prevention. A few years since I saw a little boy, who 
in his fourth year was observed by his parents and myself to be daily solilo- 
quizing in rhyme and verse, of which he himself manifested no conscious- 
ness. His large head, blue eyes, transparent skin, soft muscles, and sandy 
hair were additional indications of a tubercular temperament. He had 
moreover lost a brother with encephalitis. The parents were advised to 
take no encouraging notice of his poetical effusions, to postpone teaching 
him the alphabet, to bring him up on a simple diet, and to send him as 
much as possible into the open air. This course was pursued, and the 
rhyming propensity ceased. He was kept from school till the seventh year, 
when he applied himself with astonishing success, though not urged on, but 
occasionally withdrawn, and encouraged to go at large. He is now in his 
vol. ii. 47 



738 THE PRINCIPAL DISEASES OF THE 

eleventh year, with a fair prospect of good health ; but I cannot doubt, if 
a different course had been pursued, he would have fallen an early victim of 
disease of the brain, in the form of encephalitis or convulsions, or become 
permanently epileptic. 

As in many other diseases so in this, their etiology and prevention should 
be studied together, and constitute by far the most important part of their 
history. I long to see the time when prophylaxis — which rests on etiology, 
predisposing and exciting, physical and moral — shall be elevated to its just 
and high rank among the departments of medicine ; when diagnosis, medi- 
cation, and morbid anatomy will not fill the measure of our ambition, and it 
shall be felt as a holier duty to labor for the prevention rather than the cure 
of all diseases. 

Puerile encephalitis, both simple and tubercular, is what may be called a 
common and fatal disease in our Interior Yalley, and occurs more frequently 
in the city than country. I have found it in every latitude which I have 
visited ; but we have no statistics fitted to determine its relative prevalence 
in different climates, or show whether it has any climatic relations. 

III. I do not propose to go into the symptomatology of this disease, so 
fully developed in all our standard works ; but limit myself to a few remarks 
on its forming stage. 

The symptoms, corporeal and mental, which indicate this stage, are often 
insidious and unsuspected by parents. When dependent on external vio- 
lence, whether the constitution be tuberculous or not, it is often awakened 
suddenly, and then assumes an acute character from the beginning. Yet 
such causes may be slow in developing their effects; and hence the disease, 
even in its simple form, is sometimes said to arise spontaneously, the acci- 
dent having been forgotten, or never known by the parents. Another case 
of sudden access is that in which an acute disease, as erysipelas, measles, 
scarlatina, or inflammatory cholera infantum, suffers a metastasis to the 
brain. Of the last I have seen several examples. All these are instances of 
secondary encephalitis, perhaps some of them are but sympathetic cerebral 
irritations ; but whether one or the other, they are eminently dangerous, 
and their rise should be narrowly watched by the physician. 

But a far greater number of cases come on slowly. This is especially the 
case when tubercular lesions of the brain, whether going before or accompany- 
ing the inflammation, are in question. The child keeps on its feet, but is discon- 
tented and irritable, reputed to be cross, and perhaps punished; its face is 
sometimes flushed ; its appetite and bowels irregular, its stomach unsettled, 
and at night, if closely examined, it will sometimes have febrile heat, and a 
frequent pulse.* When the child is of sufficient age, it will often complain of 

* In feeling the pulse of children when asleep, I have generally found it intermittent. When this 
observation was first made, although the child was in apparent health, I apprehended that some dis- 
ease of the brain was forming, but it was not so. I have since repeated the observation many times on 
healthy children asleep, and found the same intermissions. I do not know whether the same thing has 
been noticed by others, and my own observations are not so numerous as to justify a physiological 
generalization. 



INTERIOR VALLEY OF NORTH AMERICA. 7o9 

headache, especially after violent play or exposure to the sun, when the parents 
are apt to ascribe it to a cause which, if the brain had not been previously 
diseased, would not have produced it. These symptoms should, in all cases, 
suggest forming disease of the brain j but especially if the child be known 
to have a tubercular diathesis, — if either of the parents has died of con- 
sumption, or a brother or sister labors under scrofula, or has died of 
encephalitis. When difficult or painful dentition is the exciting cause, the 
symptoms may be nearly the same, and may cease under the use of the 
gum-lancet and free purgation. If worms excite an intestinal irritation 
that is propagated to the brain, the abdominal and cerebral symptoms will 
be combined, and the whole may cease under the use of an active vermi- 
fuge ) but as a predisposition to encephalitis may be the condition which 
gave to the verminous irritation an influence on the brain, the disease 
forming in that organ may be only abated, not arrested, by the expulsion of 
the worms, and the little patient should be narrowly watched for some time. 
Again, hooping-cough, not so much through the innervation (like worms 
and teething) as through the circulation and the respiration, becomes com- 
plicated with encephalic symptoms, which from their earliest manifestation, 
should be regarded with concern. Still further, chronic cholera infantum 
insidiously affects the brain, or encephalic disease contributes to keep up 
that affection. A diarrhoeal condition of the bowels continues long after 
the season for cholera infantum is past, and resists all medication, diet, and 
country exercise. If closely examined, the child is found feverish at night. 
It loses flesh, and is unhappy and fretful, with an anxious expression of 
countenance. The whole disease is too often referred to the bowels, both 
by physician and parents, till the sudden supervention of convulsions, hemi- 
plegia, dilated pupils, and strabismus, or a part of these symptoms, declare 
the existence of a fatal encephalic affection. Finally, as in the encepha- 
litis of adults, few or no direct and obvious cerebral symptoms may occur, 
but in their place the disturbed function of some distant organ ; an example 
of which I once met with in a little child, which showed scarcely any sign 
of disease, but a certain degree of emaciation, and a hectic cough, over 
which medicines exerted no control. At length several symptoms of dis- 
eased brain, including palsy of one side, and convulsions of the other, sud- 
denly supervened, and the patient died; but the mother would not permit 
& post-mortem examination for the purpose of ascertaining the true character 
of the disease. 

IV. Pathological anatomy has done more in revealing the inflammatory 
character of the disease we are now studying, and in placing it among the 
simple or tubercular phlegmasia, than in fixing on any particular portion 
of the brain as its specific seat. The lesions are, in fact, formed in almost 
every part, membranous and parenchymatous, in different cases ', but oftener 
in and around the ventricles than elsewhere. As far as the treatment is in 



740 THE PRINCIPAL DISEASES OP THE 

question, it can signify little or nothing in what part the inflammation is 
seated. Whether simple or tubercular in its type, the serous effusion is 
not always present, and the membranes are sometimes dry, yet it is gene- 
rally more copious than in the encephalitis of adults. This, I take it, 
depends on two causes ; first, the low grade of inflammation in a protracted, 
early, or forming stage, in which condition the vessels throw out serum 
with but little or no fibrine, as in simple hypersemia; second, the fact that 
the patient is young ; for it seems probable that in childhood the albuminous 
elements relatively predominate over the fibrinous and purulent. This 
secretion has been found in every available cavity within the cranium, the 
arachnoid sac, the subarachnoid cellular tissue of the convolutions and 
base of the brain, lastly and chiefly, in the ventricles. 

The next secretion is the fibrinous, indicative of unquestionable inflam- 
mation, and generally found in and beneath the arachnoid, rendering it 
opaque; but sometimes on the lining membrane of the ventricles and the 
plexus choroides. In other cases, it exists as detached shreds and flakes in 
the serum, which it renders more or less turbid. 

Purulent secretion seems but seldom to occur, our books say little of it, 
and I have not met with it in a single case. 

A state of capillary hypersemia in both the pia mater, and the substance 
of the brain, cortical and medullary, is often present. In some cases it 
seems nothing more than simple congestion, as the blood may be squeezed 
from the part, but in others it is retained in them by the presence of an 
excess of fibrine. But in many instances the veins and sinuses are engorged, 
and the congestion is chiefly venous. 

As to the texture of the brain, it is frequently softened, especially around 
the ventricles. 

Any or all of these pathological lesions may belong equally to simple and 
to tubercular encephalitis, but the latter is distinguished from the former, 
by the superadded deposits of tubercle, which is found scattered in granules 
or larger masses in or upon the arachnoid, and sometimes in the cerebral 
substance. The presence of the same heterologous secretion, is in some 
cases evinced, by the altered and imperfect character of the fibrinous de- 
posits on or beneath that membrane. These bodies constitute the sole ana- 
tomical distinction between simple and tubercular encephalitis ; and as they 
are not very common, it might be concluded that this form of disease is 
uncommon. I have not, however, used the word tubercular in reference to 
deposits in the brain as to the diathesis of the patient, and should not hesi- 
tate to apply it to a case in which no tubercles were found, if the evidence 
of such a diathesis had existed. It is not the deposited tubercle merely, 
but the lesion of the constitution which nullifies the antiphlogistic treatment, 
and leads to a fatal termination. 

V. It will not be necessary to devote much time to the treatment of this 
affection after what was said under the head of cerebro-meningitis. In pro- 



INTERIOR VALLEY OF NORTH AMERICA. 741 

portion as the patient is free from a tubercular taint is the prospect of a 
cure, whether we are called in during the forming stage or not until the 
disease is fully developed. In both varieties, cases which have a long and 
stealthy access are at least amenable to medicine. It is not easy to say 
what should be done during that stage, except to obviate every discoverable 
exciting cause, whether it be external or internal and pathological. In 
some cases the arterial excitement never rises high, and an active antiphlo- 
gistic treatment seems inadmissible. Purging, minute alterant doses of 
calomel, a few leeches to the head, cool applications subsequently, and occa- 
sionally small blisters to the ankles and nape of the neck, dressed with 
emollient poultices, comprehend the whole treatment. 

In cases more acute and violent the same remedies may be employed in 
larger measure. I may say a few words on each. The lancet is indispen- 
sable, and when, as sometimes happens, it cannot be employed in the arm, 
the jugular vein should be opened; but the child should not be bled to 
syncope. The venesection may be repeated once, and in a few cases oftener, 
when leeches should be employed. Experience has taught me, however, 
that when this inflammation is developed in a tubercular constitution, the 
results of copious bloodletting are by no means satisfactory, although the exist- 
ing symptoms may seem to require it. Of the safety and probable benefit of 
active purging in this state of the system there can be no doubt. But many 
physicians have placed their chief reliance on calomel, and the outward 
application of mercurial ointment. I have seen this treatment carried very 
far, but am not prepared to commend its unlimited employment. The 
object is to excite a mercurial disease which shall set aside the other. It 
is, however, extremely difficult thus to affect the system of small children, 
and when successful, the danger of sloughing ulceration or gangrene of the 
mouth is great. Nor can I approve of the extent to which blistering is 
sometimes carried in this affection, especially when the cuticle is removed 
and irritating unguents are applied instead of soft poultices. The nervous 
systems of children are too susceptible to justify such irritation. It may 
be said, however, that the patient without these means will die, and they 
may do good ; but on the other hand it may be said that with them they 
generally die, and that it remains yet to be determined whether as great a 
number would not recover under a milder process of medication. 

That the systems of little children are easily brought, by copious bleeding, 
purging, and extensive blistering, into a state of severe and often fatal irri- 
tation, I have no doubt ; and therefore believe that they, more than adults, 
require the early administration of gentle opiates and diaphoretics, with the 
tepid bath. 

In the earlier stages of the disease, the occurrence of a convulsion need 
not excite very deep concern ; but in the more advanced stadia, that symp- 
tom, with paralysis, dilated pupil and coma, presents a case which may be 
expected to prove fatal, and it signifies little what may then be done, as from 
the insensibility of the patient the harshest measures are perhaps not felt. 



742 THE PRINCIPAL DISEASES OF THE 

VI. The following case seems referable to the head we are now under. I 
propose to append it here, because its symptoms, observed and recorded with 
care, present several anomalies. (Med. Notes, 1st Series, Vol. 7, p. 101, 
A.D. 1841.) 

D. M., a male infant, was well developed at birth, had the aspect of a san- 
guine-lymphatic temperament, grew rapidly and displayed early intelligence 
with fine moral dispositions. He was generally of a costive habit. In the 
month of February, 1841, when he was eleven months old, he was attacked 
with what seemed a catarrhal cough, accompanied with slight fever, for 
which he took gentle antimonials and other sedative expectorants, under 
which he neither got well nor became seriously ill. His cough continued 
through March and April, affecting him more by night than day, and often 
assuming a kind of paroxysmal character, but without the characteristics of 
pertussis; nor was that disease then epidemic. The feverishness of the 
commencement ceased, and the respiratory sounds were perfectly normal. 
His appetite was regular, but he lived chiefly at the breast. The latter part 
of April found him with less cough, but losing flesh, and extremely fretful 
and discontented, with long fits of crying. His bowels had now become 
more regular. In the first few days of May, these symptoms were more 
urgent, and his aspect became languid and haggard. On the morning and 
forenoon of the fourth of that month he was observed to be unnaturally 
dull and sleepy ; the following night he was restless, but the next day and 
succeeding night had extreme drowsiness. On the sixth, it was difficult to 
arouse him. For several days his pulse had been about ninety in a minute 
— regular when awake, and irregular while asleep. He had neither febrile 
heat nor thirst, and his bowels were open without the use of medicine. On 
the seventh, he took six grains of calomel, and slept through the day with 
breathing (as before) tranquil and almost inaudible. In the afternoon he 
had one copious yellowish evacuation. Not being relieved from the drowsi- 
ness, he was now bled to the extent of six ounces, which brought on vomit- 
ing, and left him with a strong tendency to syncope for an hour. The 
serum of the blood was a little milky, and the clot displayed a slight degree 
of siziness. A second yellow evacuation followed the bleeding, after which 
he was put in a tepid bath, and appeaing much exhausted, took a small dose 
of paregoric. He lay all night without moving or waking up, but had no 
perspiration. The next day (May 8th) continued in the same condition. 
In the morning five grains of calomel were administered, which was followed 
by two evacuations — one green the other yellow. In the evening his pulse 
was 112, and he had a little febrile heat. Granville's liniment was applied 
to the back of his neck till it raised a few small blisters. At bedtime the 
calomel was repeated. From 11 p.m , till 6 o'clock, p.m., of the next day 
(9th) he lay in one position apparently asleep. At the latter hour he was 
found to have some fever. Took the breast, as he had done before, but 
would not notice anything. A blister was now applied to his neck, and ano- 



INTERIOR VALLEY OF NORTH AMERICA. 743 

ther dose of calomel administered. In the afternoon eight leeches to his 
temples, bled freely. Another dose of calomel was exhibited, and followed 
by an infusion of spigelia and senna. A slight perspiration followed. At 

10 p.m., had one evacuation — no worms. The medicines were continued, 
and the blister poulticed. Pulse 108. Takes notice of some things. Morning 
of the 10th. Has had no evacuation. Seems more awake, and a little 
thirsty. Takes things in his hands and applies them to his mouth. Pulse 
variable between 94 and 100. Took castor oil and oil of turpentine. One 
P.M., has had an evacuation — no worms. Quite awake, skin cool and no 
thirst. At sundown, comatose, pulse extremely irregular and variable, 
sometimes remarkably full, constantly soft. Eight leeches were applied to 
the upper part of the forehead ; bleeding, but moderate. Gave ten grains 
of calomel. At 8 o'clock, on a careful examination, the sounds of the heart 
were loud, its impulse feeble ; the resistance of the carotid, temporal, and 
brachial arteries was small. With all this enfeeblement of the more cen- 
tral parts of the apparatus of the circulation, there was in his fingers and 
toes, especially the former, a strong, vibratory pulsation, perceptible to their 
very extremities, which, in fact, I had accidentally noticed, in a slighter de- 
gree, the day before. It was synchronous with the pulse, and arrested by 
compressing the brachial artery. His skin was of a natural and uniform 
temperature ; his tongue clean, and his gums healthy in color and fulness. 

11 p.m. At 9 had an evacuation of mucus, mixed with bile. Now lies 
comatose, and cannot be roused. Pulse 90 to 108, soft and irregular. Warm 
bath and blister to the crown of the head. May 11th, morning. Some- 
what restless, pulse more frequent, constant rubbing of his nose and left ear 
with his left hand. At 9 o'clock, an evacuation of the same kind with the last 
— no worms. Pulsation in his fingers as before, and their ends red. 10 o'clock. 
Pulse 116, no flush of fever, no thirst, skin soft, comatose and quiet. A 
dose of calomel and ipecac. — vomited twice. 11 p.m. Comatose through- 
out the afternoon and evening. Pulse of continued variability, ranging 
from 90 to 110 ) skin natural, countenance soft and quiet. Blister over 
the parietal and temporal bones. Broken doses of calomel and ipecac. 
12th, 9 a.m. From 12 to 5 a.m., his breathing a little laborious, vomited 
several times; at this time his pulse 132, irregular, and sometimes inter- 
mitting after every fourth beat, deeply comatose ; no medicine. At noon, 
had an injection which operated. At two, dressed the blister on his head, 
which had drawn well. 4 p.m. For the last two hours has been most of 
the time awake, manifestly sees and hears, and displays muscular move- 
ments indicative of attention. Countenance tranquil, with a very soft and 
pleasant expression ; sometimes evidently looks at things presented, but 
generally his eyes are in a fixed direction ; his left hand, which was yester- 
day in almost constant motion, is to-day still, and his right is perpetually 
moving in an idle chorea-like manner. Pulse 120, and perfectly regular. 
Drinks what is offered to him. 9 p.m. A tepid bath, and blister between 



744 THE PRINCIPAL DISEASES OF THE 

the scapulae. Hands at rest, sleeping, or in coma, breathing easy. Soon 
afterwards, the movements of the right hand recommenced, and his eyes as- 
sumed a fixed direction; his hands became warm and the palms and tips of 
the fingers were red; noticed things, and grasped a watch with both hands; 
utters no vocal sound of any kind, now and then coughs, with a slight mu- 
cous rattle. 13th, 8 o'clock, a.m. From an injection, has had one copi- 
ous evacuation. Seems wide awake, and notices many things, but neither 
smiles nor cries ; perspired after swallowing milk ; pulse more regular ; 
aspect of the case encouraging. 10 p.m. The apparent tendency to conva- 
lescence has not continued. Most of the afternoon has taken no notice of 
anything except when applied to his mouth ; arms, hands, and fingers of 
both sides in perpetual motion; feet the same; pulse regular but more fre- 
quent; more thirst, and cheeks now and then flushed; leeched on the fore- 
head and epigastrium — not much bleeding, but the flush of the face removed. 
14th. The chorea-like movement of his limbs continued till 4 this morning. 
At 7 he had slight strabismus of the jight eye, but no dilatation of the 
pupil, and was pulseless ; at 8 he expired without a struggle. 

It is much to be regretted that a post-mortem inspection was not permitted 
in this case. In the absence of the light it might have thrown on the na- 
ture of the disease, it will not be admissible to say much, but I will venture 
a few remarks. Notwithstanding the absence of so many of the symptoms 
which characterize what is denominated hydrocephalus, this case must, I 
think, be referred to that head, and to that subvariety which I have desig- 
nated by the terms tubercular encephalitis; or inflammation of the brain, 
occurring in a tubercular diathesis, when, as a general fact, it is mild but 
obstinate. It probably began in February when the cough set in, and occa- 
sioned that symptom, instead of being a metastasis of pulmonary disease. 
Its most acute stage was in March and April, when the little patient seemed 
from his long spells of irritable crying 'to be in pain. The costive habit of 
that period and before, was what might be expected under an affection of 
the brain. But as he seldom had any perceptible fever, and his system was 
not tolerant of bloodletting, the phlogistic diathesis was of the lowest grade. 
Coma was obviously the prominent cerebral symptom ; but why should de- 
lirium, convulsions, paralysis, and dilated pupil be absent ? 1 can only con- 
jecture that there was general congestion, and slow, serous exfiltration, by 
which gradual and uniform compression of the brain was brought about. 
The accumulation was probably in the ventricles, and equal on both sides. 
But how are we to account for the abatement of coma and the integrity of 
intellect, sensation and volition, only the day before his death ? This has 
been observed in other cases, but a precedent is not an explanation. I can 
only conjecture, that a part of the cerebral compression might have depended 
on congestion, perhaps venous, and, at the time of which I speak, it might 
have been temporarily diminished. Its recurrence the next day might have 
been the immediate cause of death. Such fluxionary congestions are not 
uncommon. 



INTERIOR VALLEY OP NORTH AMERICA. 745 

The singular movements of the extremities, a sort of compound of sub- 
sultus tendinum and chorea, occurring first on one side, then on the other, 
and then on both, with the periods of fixed direction of the eyes, seem to 
have been the equivalents of the spasm and partial paralysis, so characte- 
ristic of the last stage of ordinary subacute encephalitis. The redness and 
vibratory pulsation of the extremities of the fingers and toes, I would 
ascribe to a tubercular diathesis. They seemed to me exceedingly like the 
affection of those extremities, so often met with in the closing stages of 
phthisis ; and, more fancifully, I would refer the placid and almost smiling 
aspect of the little patient in the last days of his illness to the influence of 
the same temperament on the mind and moral feelings of the patient. We 
often see the same aspect in those who are dying of tubercular consumption. 

The ineflicacy of our received method of treatment was fully shown in 
the progress and termination of this case. The bloodletting, judging by 
the quantity drawn compared with the age of the patient, and by its imme- 
diate effects, was carried to its admissible limit's without any benefit. It 
must be admitted, however, that if it had been employed several weeks 
before, the result might have been different ; yet at that time the child 
showed no evidence of a phlogistic condition, and was not indeed regarded 
as requiring treatment. Calomel, purgatives, and blisters were all employed 
extensively, but with no permanent and little apparent benefit. The blisters 
only seemed once or twice to mitigate the symptoms. Finally, assuming 
this to have been a case of that form of disease to which we have devoted 
this section, we see how insidiously it may establish itself; and how fruit- 
less in some cases may be our curative efforts, although begun as soon as 
any ordinary signs of encephalic disease appear. 



CHAPTER IX. 

INFLAMMATIONS OF THE NERVOUS CENTRES— BRAIN AND SPINAL 
MARROW CONTINUED— MYELITIS AND CEREBRO-MYELITIS. 



SECTION I. 
SPORADIC MYELITIS — PARENCHYMAL AND MENINGEAL. 

I. Prevalence. — 1. No organ of the body is as well defended against the 
direct action of mechanical and other external causes of disease, as the 
spinal cord. Compared with the brain it enjoys a high degree of security. 
It would not be difficult to show that the osseous case in which it is enclosed 



746 THE PRINCIPAL DISEASES OF THE 

has a structure much better fitted for defence than if it were a solid cylin- 
der of bone. Then for three-fourths of its circumference it is protected by 
the thoracic and abdominal viscera with their bony or muscular walls, while 
the large and firm muscles of the back with the broad scapula afford for 
much of the remaining fourth a very adequate protection. In falls, these 
parts very commonly bear a large part of the shock, and thus diminish the 
concussion of the cord. The brain in all these respects is much less pro- 
tected. 

2. The spinal cord is less copiously supplied with blood than the brain, 
and therefore less liable to congestion and inflammation, and less acted on 
by deleterious agents received into the circulation. The blood enters it, 
moreover, by many small arteries, and thus the medullary matter is defended 
against the impulsion which the cerebral matter suffers in hypertrophies 
and excited functional conditions of the heart. Hence it is that spinal 
apoplexy is rare compared with cranial. 

3. The stomach is the organ on which the superabundance of food and 
stimulating drinks, with a vast number of irritating agents (causae morhi) 1 
make their primary impression. Now, through the pneumogastric nerves, 
the brain is affected by these influences, far more directly and frequently 
than the spinal cord. 

4. The functions of the cord are few and simple compared with those of 
the brain, which is the seat of perception in reference to all the special 
senses and appetites, of the passions and emotions, of the will and of the 
rational faculties, to say nothing of the influence which it appears to exert 
over most of the functions of organic life. But the spinal cord performs 
only the functions of transmission to and from the brain j and the reactive 
function, denominated excito-motory. In its transmitting functions, it is 
perhaps as simple and passive as the wire between two telegraph stations. 
The sensific impression being conveyed by it to the brain, and the motific 
impulse returned through it to the muscles. In regard to the excito-motor 
movements, occurring independently of the brain, they present an aspect of 
simplicity, so great as to suggest the illustration afforded by mere mechani- 
cal rebound. There seems indeed to be a perpetual gentle exercise of this 
function sustaining the muscular apparatus in its ordinary condition, while 
under the influence of stimuli it may be quickened or rendered abnormal. 
Seeing this difference in the specific functions of these two divisions of the 
cerebro-spinal system, we might expect the diseases of the latter to be few 
compared with those of the former. 

Both semeiology and pathological anatomy declare this to be the fact; yet 
we may possibly underrate the prevalence of spinal inflammation and 
apoplexy, seeing that in many of our post-mortem inspections which com- 
prehend the brain, the spinal cord is left unexamined. 

Nevertheless, myelitis, both meningeal and medullary, is unquestionably 
a rare disease in our Interior Valley, notwithstanding the vast labor and its 



INTERIOR VALLEY OF NORTH AMERICA. 747 

casualties, connected with the destruction of our forests, the construction 
of houses and public works, and the handling and exportation of countless 
tons of agricultural produce annually ;* and this rarity, I think, must be 
chiefly ascribed to the sources of anatomical and physiological sources of 
immunity which have been pointed out. 

II. Myelitic Irritation. — While inflammation of the spinal cord is a 
rare affection, irritation of that organ is regarded by our profession as a 
common disorder. This opinion has been gaining ground for the last 
twenty years, not, I apprehend, from any increase of that malady, but from 
the attention of physicians having been more directed to the spine than for- 
merly ; and from many disordered functions of the heart, lungs, and stomach, 
which were once held to be primary irritations of those organs, being now 
regarded as secondary, and dependent on myelitic irritation. The proper 
place to discuss this subject is that assigned to the neuroses, but as irrita- 
tion frequently eventuates in inflammation, and as the distinctive diagnosis 
in many cases presents much difficulty, it is necessary to refer to it here. 
That the nervous matter in whatever part of the body or under whatever 
form it may exist, can be thrown into a morbid condition without the co- 
existence of capillary hypersemia cannot, I think, be doubted. To this 
condition taken in the concrete (for a distribution is impossible) we may 
provisionally apply the term irritation, which used metaphorically, involves 
no hypothesis. As the irritation happens to be seated in the nervous 
matter appropriated to sensibility, or to mobility, the morbid phenomena re- 
sulting from it will be those of sensation or motion ; and when it occurs in 
nerves, or at the origins of nerves presiding over the nutritive functions, the 
symptoms will be found in their disordered condition. Now the spinal 
cord is not only made up of nerves of sensation and motion, but sends twigs 
into the ganglia and plexuses of organic life. Still further, it seems to give 
origin to most of the nerves which combine and bring into coetaneous action 
the numerous muscles of respiration. Here, then, is a broad foundation for 
the symptoms of what, in the popular language of the profession, are inac- 
curately called spinal irritations. Varying according to the seat of the 
myelic irritation, a chapter would be necessary to a full enumeration of 
them. In the organs of sense, morbid sensibility of the eye and ear; in the 
apparatus of locomotion, pains, soreness, numbness, cramps, sometimes 
spasms, badly directed voluntary movements, and reduction of energy; in 
the muscles of respiration, convulsive, paroxysmal cough, and feeling of 
constriction ; in the heart, palpitations ; in the stomach, gastrodynia, and 
flatulence, and variable appetite ; in the bowels, constipation ; in the kid- 
neys, increased and limpid secretion. These, however, are but specimens 
of the groups of symptoms which are assumed to depend on myelic irrita- 
tion. In many cases, doubtless, the spinal cord is not in fault; in others 
affected secondarily but reactively, giving birth to added symptoms. 

* See Vol. I., Book I., Part III. Chap. IV. 



748 THE PRINCIPAL DISEASES OF THE 

But how can we decide that the cord is the seat of irritation ? To declare 
it on the authority of these symptoms would be a petitio prindpii, yet if 
we see them subdued by measures addressed to the spine, we acquire pre- 
sumptive proof of such an origin. The absence moreover of the signs of 
congestion, inflammation, or any anatomical lesion in organs, the functions 
of which are disturbed (as for example the sounds of the lungs being natu- 
ral, in the midst of a convulsive and persisting cough), will afford further 
presumptive proof. Finally, a state of morbid sensibility or tenderness of 
some portion of the spine, under pressure, and especially a momentary in- 
crease of the symptoms in distant organs during such pressure, will, the 
other means of diagnosis concurring, generally lead us to a correct conclu- 
sion. Not, it is true, to the conclusion that a simple " nervous" irritation, 
but that a morbid condition of some part of the cord is present. It will, 
therefore, remain to decide whether it be non-phlogistic irritation or inflam- 
mation, and this cannot always be easily done. Pressure as a general fact 
will give pain in both cases ; but under strong pressure or violent percussion 
or rapid tortuous motion of the spine, the pain will be more increased when 
inflammation is present than when it is absent. In making this pressure, 
we must never forget that when there is no disease of the cord, there is a 
certain degree of relative tenderness about the fifth and sixth dorsal vertebrae, 
corresponding with the physiological intolerance of pressure found in the 
epigastrium. The sponge dipped in hot water is perhaps of more value in 
this diagnosis than pressure. It may not always increase the pain when 
there is myelitis, but when it does have that effect inflammation is more 
probable than mere irritation, as we find in external parts the inflammatory 
pains increased by heat, while the non-inflammatory are generally abated. 
The sex of the patient may aid us, for women are more subject to irritation, 
men to inflammation. The 'temperament and constitution of the patient 
must not be overlooked. In the sanguineo-bilious we may look for inflamma- 
tion ; in the nervous and lymphatic for irritation. Again, the symptoms are 
(irregularly) remittent or even intermittent in irritation, more persistent in 
inflammation . But finally, the absence of fever in one case, and its presence in 
another, with the general signs of a phlogistic diathesis, including a buffy 
coat of the drawn blood, will justify the diagnosis. 

III. Inflammation within the spinal column may be seated either in the 
cord or its meninges, or both at the same time. It is often complicated 
with cerebro-nieningitjs. Spinal meningitis is more acute and violent than 
myelitis or inflammation of the cord itself. The prominent symptoms are 
fever, severe pain in some part or the whole of the spine, sometimes passing 
gradually from one part to another, in many cases pains in the head, the 
parietes of the chest and abdomen, also in the muscles and joints of the 
extremities ; opisthotonos, and tetanic contractions of various muscles, 
spasms, subsultus, and partial paralysis. When the inflammation is seated 
chiefly in the cord, the pains and fever as intimated are less acute, but as 



INTERIOR VALLEY OF NORTH AMERICA. 749 

the tendency is to softening, paralysis occurs at an earlier period and is of 
greater extent. Dyspnoea, dysphagia, and retention of urine are often pre- 
sent in both. 

When these inflammations are violent and rapid, they can easily be dis- 
tinguished from irritations, but in their milder forms such discrimination is 
often difficult, sometimes, indeed, impossible till the disorders of sensation 
or motion, which arise from slow but fatal lesions of structure, show them- 
selves. 

These anatomical derangements are hyperemias and ecchymoses ; serous or 
sero-sanguinolent effusions beneath the arachnoid; fibrinous deposits on the 
surface of the cord j lymphatic adhesions of the arachnoid surfaces, suppu- 
rations, which seem to be comparatively more frequent than encephalitis ; 
finally, when the inflammation originates in, or penetrates the cord, softening 
of sections, or even its entire length. It is remarkable that in some cases 
the cord becomes diffluent, and yet voluntary motion in the parts below is 
not destroyed ; from which we learn that the cohesion of vital affinity may 
be reduced or annihilated without abolishing the function of transmission in 
the living atoms, while they are kept in mechanical contact. 

IV. Treatment. — Acute inflammation of the spinal cord and its mem- 
branes, or either, must be met by the same means as acute encephalitis. In 
estimating the condition of the system we must not forget that the influence 
which the cord exerts over the movements of the heart, may sometimes pre- 
vent the development of a true phlogistic pulse, and throw us upon pain, in- 
creased by motion, pressure or heat, and spastic contraction of the muscles, 
as evidences of high inflammatory orgasm. 

1. The first and most important remedy is bloodletting, which in many 
cases must be carried to a great extent; and when venesection seems no 
longer admissible, cupping may be employed. In mild and chronic cases, 
the local detraction of blood may of itself be sufficient. 

2. Purging ranks next to bleeding. Copious secretion and excretion from 
the bowels is in fact local depletion from the spine ; while the irritation of 
drastic cathartics effects a most beneficial revulsion from the inflamed organ. 
Calomel, followed by the compound powder of jalap, or the podophyllum 
peltatum, or an infusion of senna with sulphate of magnesia, is the most 
efficient means of purgation. The evacuations should be chiefly effected in 
the evening, and followed at bedtime 

3. By Dover's powder and calomel. This compound, after free bleeding and 
purging, fulfils three indications. The calomel acts as an antiphlogistic 
alterant, the opium allays irritation and diminishes the spasticity of the mus- 
cular system, and the ipecac, in connection with the opium determines upon 
the surface of the body and makes revulsion from the spine. The objec- 
tion to opium in encephalitis, does not lie against that medicine in myelitis, 
while the greater prevalence of spasm in the latter renders it peculiarly 
necessary. 



750 THE PRINCIPAL DISEASES OF THE 

4. Cold applications over the affected part, or when that cannot be satis- 
factorily made out, over the whole length of the spine, are of much value. 
In this affection it is necessary to make colder applications than in cerebral 
inflammation, for they are at a much greater distance from the seat of the 
inflammation, and the antispasmodic power of cold is more needed. Long 
compresses dipped in ice-water, or a series of bladders containing pounded ice 
should be laid along the spine, and frequently renewed. At the same time 
the feet and legs of the patient should be carefully kept warm, whenever 
general chilliness or shivering is produced the ice should be temporarily re- 
moved ; or it may still be continued, and the patient's system reconciled to 
its impress, by a liberal dose of laudanum. Should he at length fall asleep, 
a wet compress of the temperature of the body, and so covered as to con- 
fine the vapor, will be the most soothing and appropriate application. 

5. Of the value of blisters in this affection there can be no doubt. They 
should follow on all the other remedies which have been mentioned. The 
blistered surfaces should be dressed with emollient poultices or compresses 
dipped in tepid water. The terebinthinate and other irritating applications 
sometimes resorted to, are not suited to the morbidly sensitive condition of 
the nervous system. 

When the meninges are the seat of the inflammation, this treatment, 
begun at an early period, will generally succeed ; but if the cord itself be 
inflamed, the prognosis cannot be so favorable, as inflammation, seated in the 
nervous substance, cranial or spinal, is more difiicult to subdue than when 
situated in the investing membranes. 

V. Both acute myelitis and acute myelitic meningitis are apt to abate 
into subacute grades and become chronic ; but they may have been mild 
from the beginning. In either case, the treatment is a diminutive of that 
just laid down. Topical bleeding takes the place of general, and blisters 
replace the cold applications. When the inflammation can be clearly de- 
tected in a particular place, the actual cautery may be applied, and an issue 
maintained for a long time. As a substitute for both, pustulation may be 
produced by tartar emetic ointment. When the signs of mere irritation 
predominate, the application of stramonium ointment immediately after 
applying Granville's lotion, or some other stimulant, till a rubefacient effect 
is produced, will be found serviceable. Copious purging may often be 
useful when venesection is not admissible, and an open habit of body should, 
in all cases, be maintained. The slow administration of calomel, from two 
to four grains in the twenty-four hours, till a gentle salivation begins, is not 
to be neglected in obstinate cases. The morbid sensibility and muscular 
pains, with nocturnal restlessness, often present in these cases, demand the 
use of opium or some other narcotic. The extract of hyoscyamus may 
suffice, and has the advantage of not producing constipation ; but, on the 
whole, Dover's powder, or a syrup of sulphate of morphine, with wine of 
ipecac, or laudanum and antimonial wine, is preferable. 



I >' I E R I :- ?. VALLEY OF XORIH AMERICA. 751 

Thronghout the whole treatment of chronic, not less than acute myelitis, 
unbent position will be proper, and great muscular effort of every kind 
should be avoided. 



SECTION II. 

EPIDEMIC CEREBROSPINAL X EVEN 01 ITS 

I. History. — We have, thus for, been occupied on spa ::'': ir.flamraa- 
tion of the membranes and medullary substance of the brain and spinal 
cord ; but it sometimes occurs as an ej: . and then requires a separate 

examination. I: is remarkable that this epidemic should have been first 
noticed in our Interior Valley and on the Continent of Europe about the 
same time — 1840-41. It appears, however, from retrospective inc. 
that it had prevailed in Europe long before, though described under various 
names, none of which suggested its true character. It has never fallen 
under my own observation. It has not, I think, been described among the 
epidemics of the Atlantic States. Of its occurrence in our Interior Valley, 
I have met with the following notices. 

In the month of January, 1842, :: lommenced as an epidemic in Ruther- 
ford County, Tennessee.* About the same time it began rather sporadic- 
ally at Montgomery, Alabama ;f becoming decidedly and suddenly epidemic 
in the month of February, 1848, and ceasing with the month of May, tc 
reappear soon afterwards on some of the surrounding plantations.!: In the 
autumn of 1845. and the following winter, it prevailed at Mount Ve:_ n 
and other places, in Southern Hlinois.§ In the month of January. 1847. it 
at Vicksburg, Mississippi, and continued till the close of March. I j 
In Hardaman County, West Tennessee, it appeared in February, and con- 
tinued through the* spring. r Id 1846-7, it was observed at BentonviUe, 
Arkansas . and at the same time cases appeared in Union County of 
that state."j~|" In January and February, 1847, a regiment of United 
States recruits, from the State of Mississippi, suffered severely from it in 
the vicinity o: New Orleans,}} and in February, 1850, it was unserved tc 
some extent among the population of the eity.§ : 

All of these localities lie South of the thirty-ninth parallel of latitude, 
and most of them have a winter mean temperature corresponding to that of 

* John W. Biehardson. M.D. Western Journal (Lonisvffle) for December, 1842, p. 430. 

t W. W. BoCing, MD. Xew Orleans Med. Jonr. for May. 1847, p. 732. 

{ S Ames, M J). Ibid- Not. 1S4S. p. 295; alio, in a separate monogr;:..: MmtuntM/j Ala, UH& 

§ J. C. Gray. MJ). Western Lancet for May. 1845. p. 14, 

| B. J. Hkks. Xew Orleans Med. Jonr. for July, 1*47. p. 53. 

r Z 7. White.. MJ). Ibid. p. 49. 

«* Dr. Bell West. Lancet for Nov., 18f7, : '..' 

ft Br. Charles Chester. X. 0. Jonr. for Not., 1847, p. 314. 

zzTz : I:- :;:.. 5_r ? . ~. ; . .-... :•";- ::".,:.-= •::■-.::: ."-> 1:^ ; , E 

gS.S. Fenner. M.D. South. Med. Eep., toL iL p. 17. 



752 THE PRINCIPAL DISEASES OF THE 

France and Ireland, where tbe disease has chiefly prevailed. Neither my 
personal researches in the higher latitudes of the Valley, nor a reference to 
medical journals, affords any evidence of its prevalence in those colder 
regions. Thus it has prevailed in the climates most infesied with autumnal 
fever, and all the localities in which it has occurred are subject to that 
disease.* In every instance it was a winter or early spring disease, and 
generally commenced" about as long after the winter solstice as autumnal 
fever begins after the summer ; conforming in time to vernal and relapsing 
intermittents, and corresponding in time with our pneumonias, and the 
greater number of invasions of measles. In occurring in a few localities, 
and passing by many more, it followed the same law with erysipelas, which 
was epidemic, as we have seen, during the same period. 

It attacked the people of both town and country, but with the exception 
of a few cases in New Orleans, not those of cities. Although so frequent 
in the soldiery of France, especially new recruits, it seems to have invaded 
ours in a single instance only. Blacks and whites were both attacked. 
Children, and young persons of both sexes, were its greatest victims ; but 
adults of almost every age were liable. 

According to Dr. Ames, there were in the town of Montgomery about 
250 cases, the population being four thousand; thus six and a quarter per- 
cent, were attacked. Of 85 cases, the histories of which were written, 22 
were whites and 63 blacks. He was not able to give the relative population 
of the two races ; but it may be received as a fact, that the latter were more 
liable than the former. The following table shows the relative ages and 
sexes of the different patients : — 



Up 


to 6 years, 




< 10 


<< 




< 21 


(< 




■ 31 


«< 




■ 41 


a 




' 51 


n 


Abo 1 


re 50 


(< 



ITES. 


BLACKS. 


1 


1 


2 


6 


8 


15 


3 


24 


3 


10 


2 


5 


3 


2 



22 63 

Of the whites there were 10 males and 12 females; of the blacks 36 
males and 27 females. The greatest prevalence among the whites was 
from the 10th to the 21st year; among the blacks from the 21st to the 31st; 
during which periods, it was about one-third of the whole for each race. 

II. Symptoms. — I have compared the symptoms of the epidemics of 
"Western Europe and our Interior Valley, and am satisfied that they indicate 
one and the same disease; but in the brief history on which we are entering, 
the facts and observations will be drawn from our own writers. The fullest 

* See Vol. I., Book I., Part I. 



INTERIOR VALLEY OF NORTH AMERICA. 753 

account is that given by Dr. Ames, whose paper is, in fact, an excellent 
monograph of the epidemic, while the others are but brief, yet significant 
and instructive notices. His account embraced eighty-five cases, sixty-four 
of which were subjected to a regular analysis, which my limits, however, do 
not permit me to follow out. 

All our observers have seen this disease commence and advance in a mild 
and gradual manner, and also with suddenness and great violence. Most of 
the symptoms are found in the functions of sensation and motion. In a 
great majority of cases, the onset was with pain, always in the head, but 
likewise in various parts of the body, as in the neck, and, indeed, the whole 
length of the spine, and in the muscles and joints of the extremities. It 
frequently changed its place, except when located in the head and neck. 
In many instances it was of the acutest kind, and in some patients there 
was such a general morbid sensibility that the slightest touch would make 
the patient start with a kind of general spasm, as in hydrophobia, and 
scream out with pain, which he could not refer to any particular part. 
When the pain did not give place to coma, it often continued to the close of 
the disease, especially in the head and neck. The latter was often tender 
to the touch, and in some patients pressure over the cervical vertebrae 
caused an acute pain to dart from that part into the head and eyes, and 
when made lower down gave pain in the sternum, the epigastrium and the 
abdomen. 

In some patients there was coma on the first day, which ceased and re- 
curred ; in others it set in at a later period. "When it did not remit, an 
early and fatal termination occurred. 

Delirium was generally present. It sometimes began with the disease. 
It was either mild and muttering, or furious, even to a kind of maniacal 
frenzy. 

The pupils were sometimes contracted, in other cases dilated, and in 
some, one was in the former, the other in the latter condition. In a few 
there was temporary blindness ; in many double vision. In a few cases the 
senses of taste, smell, and hearing, were impaired or lost. 

From the beginning there was also great muscular weakness, and in 
some patients tremors, twitchings, or perpetual motion of the limbs. The 
muscles most affected, however, were those of the trunk of the body, which 
experienced those tetanic contractions, which, in fact, constitute the most 
pathognomonic symptom of this malady. In some cases there was trismus, 
and in a few emprosthotonos; but in the majority the extremities of the 
spine were thrown backwards till it was bent like a bow, constituting opistho- 
tonos. This curvature did not in general begin with the attack, but ap- 
peared in various stages of the disease. In a few patients there was spastic 
rigidity of both the flexors and extensors of the head and neck, so that no 
motion could take place, and the same condition of a limb was occasionally 
seen. General convulsions occurred in many cases. 

vol. ii. 48 



754 THE PRINCIPAL DISEASES OF THE 

Paralysis was not uncommon. Strabismus occurred in several cases ; in 
one patient the upper eyelid of one eye was paralyzed ; in some an arm or 
a leg was brought into that condition, and in a smaller number there was 
hemiplegia. 

Many additional pages would be necessary to a full exhibition of the 
functional derangements of the organs of sensation and motion ; but we 
must pass on to others. 

The greater number of cases were ushered in with a chill, which was of 
varying intensity and duration, from the slightest rigor to the degree which 
in some places procured for the disease the name of " cold plague." In 
many cases the chill was not repeated, but in some it returned daily or at 
irregular periods. When the onset of the disease was marked by apoplec- 
tic stupor, the chill was frequently absent or not detected. The reaction 
was often so imperfect, that the heat of the surface continued too low 
throughout the whole course of the disease, but in some cases it rose to that 
of well-developed fever. 

The state of the circulation was various. In some cases it was but little 
affected; but in the greater number the heart manifested enfeeblement and 
vacillation. The pulse, scarcely ever tense, was, in a great majority of cases, 
soft — often preternaturally slow ; in many intermittent and indistinct — in 
some quite absent. The capillary circulation seems to have been equally 
enervated ; as was evinced by the low temperature of the surface in many, 
by pallor, and in numerous instances by petechias or extensive ecchymoses. 
Instead of these capillary lesions, some had an eruption resembling nettle- 
rash, and others an efflorescence not unlike that of scarlatina. 

The respiration was generally increased in frequency — in some cases 
amounting to fifty inspirations in a minute ; in a few it was stertorous and 
slower than in health ; in others difficult, apparently from the spastic con- 
traction of the thoracic muscles. 

The digestive functions appear to have been less affected than any other 
class. The tongue was sometimes quite natural, in other cases more or less 
furred. It was often pale, and so spread out as to be indented on its sides 
by the teeth. In the progress of protracted cases it sometimes became 
brown and dry. In some the appetite was good up to the access of the dis- 
ease, and even afterwards. But many had gastric irritability with vomiting. 
The bowels were natural or costive, though in some instances diarrhoea ex- 
isted in the beginning, or began in the course of the disease. Abdominal 
swelling and tympanitis seem to have been rare. 

I have preferred to make this rapid enumeration of symptoms, as they 
appeared in the great functions of the body, to classing them according to 
the so-called stages and varieties of the disease ; for, as in the case of our 
malignant autumnal and typhous fevers, such a classification is nearly im- 
possible, seeing that symptoms which in one patient may usher in the 
attack, will in another not occur till near its close. This in fact was an 



INTERIOR VALLEY OF NORTH AMERICA. 755 

ataxic fever, and no two of the reported cases present the same combina- 
tion or succession of phenomena. Its true diagnosis consisted in the pains 
of the head, neck, back, and limbs, almost continuous in the first, and 
changing from place to place in the last; in the delirium and coma occur- 
ring and ceasing in various stages of the malady ; in the spasticity of the 
muscular system (of animal life) generally, and above all, in the tetanic 
contractions of the muscles of the trunk, giving to the upper extremity of 
the spine a backward, forward, or lateral curvature. 

III. Pathological Anatomy. — We are indebted to Dr. Ames for 
nearly all that we know of the anatomical lesions produced by this malady 
as it appears in our Valley. 

1. The Blood. — Of thirty-seven cases in which he noted the appearance 
of the drawn blood, the coagulum was generally large, loose, and of a color 
approaching to that of arterial blood. It was buffed in four only. He ana- 
lyzed that drawn from four patients (but does not say whether they were 
those just mentioned), and found the corpuscles increased in one, dimi- 
nished in another, and natural in two. In all there was an excess of fibrine, 
the maximum being double that of health. 

2. The Brain. — Eleven of those who died were subjected to anatomical 
inspection. In two cases the dura mater showed spots of capillary conges- 
tion; in the whole the pia mater was in the same condition. The walls of 
the ventricles displayed patches of capillary hyperemia, resembling ecchy- 
nioses. In some the arachnoid was here and there thickened and opaque. 

The hemispheres of the brain, with but one exception, were in a state of 
congestion, and the blood in some of the larger capillaries was coagulated. 
In the exceptional case the gray substance was of a uniform pink color, and 
spots of a similar hue were found in the white matter. The medulla ob- 
longata, in two cases, was dotted internally with dark ecchymosed spots. 
The cerebellum participated to a greater or less extent in these hyperasmias 
in every subject. In some cases the membranes presented spots of soften- 
ing. In nine cases a similar lesion was observed in various parts of the 
brain, both cortical and medullary. The hemispheres, medulla oblongata, 
pons, fornix, septum lucidum, ventricular walls, corpus callosum, the striated 
bodies, the crura cerebri, and the cerebellum are among the enumerated 
parts. In the last organ there was red softening, which seen through the 
membranes looked like ecchymosis, and the disorganized mass examined 
under the microscope showed blood, lymph, a trace of neurine, and pus, 
which largely predominated. 

In ten of the eleven cases there was subarachnoid effusion. The fluid was 
of a yellowish color, and presented abundance of pus and lymph corpuscles. 
In some the lymph was sufficient to impart a certain degree of cohesiveness, 
with a tendency to organization. It often seemed like a layer of cream 
spread over the hemispheres ; but was most abundant at the base of the brain, 
and above all, about the optic commissure. Finally, in a number of cases it 



756 THE PRINCIPAL DISEASES OP THE 

overspread the cerebellum. In nine cases a similar effusion was found in 
the arachnoid cavity; and in one subject there was a well-organized false 
membrane. In four others the same lymphy sero-purulent secretion was 
found in the ventricles. 

Coagulated fibrine was found in the branches of the internal carotids, the 
bassilar artery, and the longitudinal sinus with its supplying veins, in a few 
cases. 

3. The Spinal Cord. — Unfortunately but few examinations were made of 
this organ. The lesions which they presented were the same as those found 
in the brain in the same subjects. The intense vascularity of the pia mater 
was always present; but the lympho-purulent effusion was less common than 
in the brain. In one subject, every portion of the cervical section of the 
cord was softened, and the lesion extended in a diminishing degree into the 
dorsal. In the same case the spinal dura mater had the color of muscle. 
In this subject the morbid effusion was chiefly about the roots of the ante- 
rior cervical nerves. 

4. The Abdominal Organs. — These were examined in five cases only. In 
the whole, the mucous membrane of the stomach was more or less reddened, 
thickened, and softened. In four of the five subjects there were lesions of 
both the solitary and agminated glands of the lower part of the ileum. In 
one who died on the second day, they were swollen, roughened with granules, 
and elevated a line and a half above the surrounding membrane, which 
near them presented arborescent capillary congestions. The mesenteric gan- 
glia corresponding to this portion of the bowel, were red and enlarged. 
There were no abdominal symptoms in this case. In another, who also died 
on the second day, the state of the bowel was nearly the same, but the gan- 
glia of the mesentery were not altered. A great many lumbrici were found 
in this case, the only abdominal symptom in which was acute pain on the 
first day. The third case terminated on the fourth day. The lower part of 
the ileum, through four feet, was examined, and the whole of its mucous 
membrane found more or less thickened, reddened, and softened. Many of 
the patches of Peyer, and a great number of the solitary glands, were ele- 
vated, and wore a granular aspect; and the cellular tissue beneath was thick- 
ened and softened. The mesenteric ganglia were normal. There were no 
symptoms of abdominal disease in this case. The fourth subject, death having 
occurred on the fifth day, presented, in the membrane of the ileum, a great 
number of nodules, which were the solitary and aggregated glands enlarged. 
Many of both, moreover, had passed on to a state of ulceration, and others 
seemed to be transformed into crude tubercular matter. The surrounding 
mucous membrane had arose color. The mesenteric ganglia, corresponding 
to the affected part of the ileum, were enlarged, of a dark red color, and 
softened. There was neither vomiting nor diarrhoea in this case. On the 
third day, being costive, he had abdominal pain, with tenderness on pressure, 
and some tympanitic distension, which were entirely removed by the opera- 
tion of a cathartic. 



INTERIOR VALLEY OF NORTH AMERICA. 757 

Of the state of the other organs of the abdomen, and those of the pelvis 
and chest, nothing was reported. 

Dr. White made one post-mortem inspection, the patient having died after 
an illness of three days. The membranes of the inferior parts of the brain 
were thickened, injected, and opaque : the ventricles contained from two to 
three ounces of transparent serum, and the lower portions of the middle 
lobes of both hemispheres, were softened. On opening the spinal canal and 
puncturing the membranes, a considerable quantity of fluid blood escaped. 
The meninges were thickened and congested. The substance of the cord 
was uninfected, but seemed slightly softened. The lungs and heart were 
normal, but the pericardium contained two ounces of serum. The lower 
portion of the ileum displayed a few spots of ecchymosis, and the liver was 
enormously engorged with blood. The other organs were normal, except a 
little enlargement of the spleen. 

Dr. Hicks made but one (hurried) examination. The cerebrum and cere- 
bellum showed no signs of disease, but the meninges of the medulla oblon- 
gata and upper part of the spinal cord were highly engorged, and the sub- 
stance of those organs presented dots of blood. 

Dr. Chester, in a single examination of the brain only, the disease having 
after its first stage assumed a typhoid character, and terminating on the 24th 
day, found the substance of the organ sound ; but the pia mater was deeply 
injected, and in its posterior part even engorged with blood. Between 
that membrane and the arachnoid there was a bloody serum, and an effu- 
sion of the same into the ventricles. 

Dr. Bell, of x\rkansas, in some examinations, saw extensive suppuration 
around the medulla oblongata. 

As the autopsies made in this country have not been numerous, it may be 
well to inquire how far they correspond in results with those made in Eu- 
rope. Without quoting authorities, most of which I have only at second-hand, 
I may say that the morbid appearances produced by the disease on the two 
continents, are almost identical.* Thus, the fibrine and corpuscles of the blood 
(in four cases) were considerably augmented; the lungs were generally sound ; 
the glands of the ileum were often diseased, but in a great number of cases, 
normal; the condition of the stomach was variable, but the cranio-spinal 
organs were always in a state of lesion. This was expecially true of the 
meninges. Hypersemia, softening, and effusions of serum, or sero-fibrinous 
fluid, or of pus, generally mingled with the others, were the common results. 
The last figures more strikingly in the autopsic reports of that country than 
our own ; and has even been regarded as the great pathological characte- 
ristic of this epidemic. The seat of the disease, in both countries, was the 
cranial and spinal organs, though it did not always affect both. I see 
nothing to justify the hypothesis, that the affection of the spinal cord or its 

* Am. Jour. Med. Sc. for April, 1843, p. 458, Oct. 1845, p. 662, and Jan. 1847, p. 152. See also the excel- 
lent lecture of Dr. Bell, Vol. II. 3d Ed. p. 427, and the art. Epidemic Meningitis in Dr. Condie's valu- 
able treatise on the Diseases of Children, p. 408. 



758 THE PRINCIPAL DISEASES OF THE 

membranes, is, as has been suggested, a mere accidental extension of the 
disease from the cavity of the cranium downward. 

IV. Modifying Influences and Complications. — Our epidemic cere- 
brospinal meningitis, has, in every locality, shown more or less of a parox- 
ysmal or remittent character, a trait which should excite consideration. It 
may doubtless be taken as a law, that all irritations, as well as all healthy 
functions, of the nervous system of animal life, have a tendency to inter- 
mittence. To this tendency we may perhaps refer the remissions, so often 
seen in sporadic and primary inflammations of the cerebro-spinal axis, from 
common causes, in localities not infested with periodical fever. But shall 
we, therefore, wholly refer the remissions and occasional intermissions of 
the fever we are now considering, to the same physiological law ? I think 
not; for, First, they are greater than those of sporadic meningitis. Second, 
the disease has prevailed exclusively in localities where the cause of au- 
tumnal fever imparts an intermittent or remittent character to many diseases 
which in other localities are continued. Thus, in these insalubrious situa- 
tions, it is not uncommon to see pneumonia and other phlegmasia, typhus 
fever, and yellow fever, display a manifest intermittence. Third, many 
cases have presented symptoms which are almost identical with those of 
malignant, ataxic intermittent fever. When giving the symptoms of the dis- 
ease we are now studying, I barely glanced at its remitting tendency, reserv- 
ing for this place a fuller statement. 

Dr. Boling generally saw the tetanic spasms preceded for two or three 
days by remittent fever. In one case it was intermittent and of a tertian 
type. After the development of the cerebro-spinal symptoms, the fever was 
regularly remittent ; and, in some cases, the tetanic spasms abated and in- 
creased with the fever; in another, both were distinctly intermittent at the 
same time. Dr. G-ray saw it marked with a decided morning intermission, 
or remission, and an evening exacerbation. Dr. Chester states that in the 
" second stage," the fever was regularly intermittent. Dr. Scruggs, also, 
observed its intermittence. He saw a patient so ill in the first paroxysm 
that she was pulseless, with intense opisthotonos ; yet the next morning she 
seemed likely to recover ; but a second paroxysm in the afternoon proved 
fatal. A young man was so well after a day of excruciating headache, that 
he went abroad, but the next paroxysm ended in death. Finally, Dr. Ames, 
in a great number of cases, saw irregular remissions ; in others they were 
quotidian or tertian, and extended both to the fever and the cerebral affection. 

In this connection I may state that Dr. Love informs us, that while the 
Mississippi Regiment was so severely afflicted by the epidemic at New Or- 
leans, the Pennsylvania troops, encamped on the same bank of the river 
hard by, entirely escaped. Now the whole were new recruits, but the latter 
were from a region but little infested with autumnal fever, while the former 
were from one which annually suffers. 

We must not conclude, however, that our epidemic spinal meningitis, ac- 



INTERIOR VALLEY OF NORTH AMERICA. 759 

tuallj arose from the same cause with autumnal fever. No doubt some 
other cause existed, which acting on systems previously impressed by that 
agency, the symptoms, type, and treatment were modified accordingly. 

This was not the only form of complication. We have seen that in gene- 
ral the lungs were unaffected, yet, occurring when catarrhal disorders were 
prevalent. Dr. Scruggs saw bronchitis with bloody sputa and dyspnoea, 
associated with supervening and fatal opisthotonos, and Dr. Ames saw three 
examples of the same complication. Dr. Richardson, where measles had 
been epidemic a few months before, frequently observed cases in which 
there was an eruption of " red specks" on the forehead, breast, and arms. 
Dr. Gray met with sore throat and a " fiery eruption," which he regarded 
as scarlatinous, in connection with opisthotonos, and deathlike rigidity 
of the limbs ; but he does not tell us that scarlet fever had previously pre- 
vailed in the same localities. At Montgomery, roseola had been just before 
epidemic, and Dr. Ames saw seven patients who had lately passed through 
that disease, affected with inflammation of the fauces, while laboring under 
meningitis, and two others, had both diseases at the same time. 

Of the relations between this disease and epidemic erysipelas,* something 
must be said. They were both in existence, as limited, or subepidemics, in 
the southern portions of our Valley through the same period, that is from 
1840 to 1850. Here and there they affected a town, village, or plantation, 
passing by a far greater number ; they both prevailed chiefly in the winter ; 
and finally in both there was a strong tendency to purulent secretion. It 
does not appear that both prevailed, in their proper diagnostic characters, 
at the same time and place ; or that one was ever the immediate successor 
of the other. The epidemic erysipelas sometimes commenced in the deep- 
seated cellular or mucous membranes, and made its way to the skin, from 
which in other cases it extended to the membranes of the brain, where its 
ravages were not unlike those of epidemic meningitis. Now, if we suppose, 
erysipelas in certain localities and times, to have commenced in the cerebro- 
spinal meninges, we should apparently have the very disease we are now 
studying, for the pseudo-inflammatory type was common to both. 

The relations between epidemic meningitis and the typhous epidemics, 
which have prevailed through the same regions of country since 1840, must 
not be overlooked. In the restriction of the two diseases to very limited 
localities, they were quite identical, and in their invasion of the nervous 
system equally so, though they did not make their attacks in the same mode. 
Yet many cases of epidemic meningitis became protracted, and put on the 
garb of typhous fever, a dark and dry tongue, subsultus, low delirium, and 
petechias or other maculae of the skin, characteristic of that fever. The 
morbid appearances of the brain and its envelopes were much alike in the 
two maladies, and in several subjects of the epidemic we are studying, there 
was tumefaction of the glands of the ileum ; facts which show that it was to a 
certain extent modified by the cause which produced the typhous fevers. 

* See Chapter on Erysipelas. 



760 THE PRINCIPAL DISEASES OF THE 

The last relation which deserves attention is that between cerebro-spinal 
meningitis, and tetanus, idiopathic and traumatic. In the northern latitudes 
of our Valley, idiopathic tetanus is almost unknown, and traumatic so rare 
that many physicians pass their lives without meeting with a single case. 
In the South it is so prevalent, that when travelling there, I found young 
physicians who, in five years, had met with more cases than I had seen at 
Cincinnati in five times that period. I refer to the tetanus of adults ; but 
the trismus of infants permits of the same contrast. A part of- this diffe- 
rence must be ascribed to the greater proportion of blacks in the South, a 
race more liable to tetanic diseases than the whites ; the remainder to the 
warmer climate; for both whites and blacks are there more subject to all 
the forms of tetanus than in our colder climates. Now, as we have seen, epi- 
demic cerebro-spinal meningitis has as yet prevailed only in the South, and it 
affected the African more than the Caucasian races. Here then are two 
points of identity in the natural history of these diseases, epidemic menin- 
gitis and sporadic tetanus. Others, still more strikingly etiological, may 
be cited. Thus, it is well known that exposure to a damp and cool atmo- 
sphere, especially through the night, is a great exciting cause of both idio- 
pathic and traumatic tetanus ; and Dr. Love, ascribes much of the fatal 
prevalence of cerebro-spinal meningitis among the Mississippi troops, to 
deficient clothing, exposure to rain, and sleeping in wet blankets, on ground 
saturated with water in the winter, below New Orleans. The Pennsylvania 
Regiment, which was encamped near them, which was from a higher latitude, 
had been longer in the field, and was well supplied with woollen apparel, as 
we have already seen continued healthy. A bad and innutritious diet has 
also appeared to co-operate in the production of tetanus, and seems to have 
been a co-operative cause among the Mississippi recruits, for they had just 
left homes abounding in healthy food, and were not reconciled to the army 
rations, which they had not the skill to prepare nor the appetite to eat. 

From these analogies in the histories of the two diseases, we might almost 
call the one we are studying, epidemic, or febrile, idiopathic tetanus; but I 
do not mean to extend the deduction any further than to recognize the causes 
of sporadic tetanus, as among those which favored the production of epidemic 
cerebro-spinal meningitis. 

V. Pathological Speculations. — After giving to climate, race, ex- 
posure, and bad diet, all the etiological influence which I think should be 
claimed for them, we must still admit some undiscovered agent, without 
which cerebro-spinal meningitis would not become epidemic. In this re- 
spect the disease stands in the same category with many other epidemics as 
the periodical and continued fevers, Asiatic cholera, and erysipelas. What- 
ever this agent may be I can no more believe that it begins its action on 
the cerebro-spinal centre, raising there an inflammation, and that inflamma- 
tion a fever, than that the causes of autumnal fever, scarlatina, epidemic 
puerperal, peritonitis, and cerebral typhous, commence their action on the 



INTERIOR VALLEY OF NORTH AMERICA. 761 

spleen, the skin, the peritoneum, and the brain. In these cases, and in that 
now under examination, a lesion of innervation, made, we know not where, 
is followed by another of the circulation, giving us, simultaneously, both 
fever and inflammation. Each of those fevers and the accompanying in- 
flammation has a peculiar type and character, and a locality of its own ; but 
both the types and locations are subject to a modification and displacement 
from causes not always perceived by us, and, therefore, the same epidemic 
does not always present the same phenomena during life, nor the same seats 
of lesion after death. 

Our cerebro-spinal fever was inflammatory; but its diathesis was not 
high.li/ phlogistic. The hyperinosis of the blood was not great, as appears 
not only from the experiments of Dr. Ames, but from the general absence 
of buff on the drawn blood, and the frequent failure — sometimes injurious 
effect — of the antiphlogistic treatment. The inflammation partook of the 
character of simple congestion, and did not bring forth the products which 
characterize the more exalted grades of inflammatory action. The lymph 
thrown out was imperfect, often greatly diluted with serum, and much 
adulterated with pus, to the generation of which there was so great a pro- 
clivity as to indicate a lesion of the blood. How far these degradations of 
the pure and acute inflammatory type depended on the nature of a special 
remote cause, on the seat of the principal inflammations, or on the agencies 
which, as we have seen, exerted a modifying influence, cannot perhaps be 
determined. I shall recognize the whole, without attempting to assign the 
value of either. 

VI. Modes or Treatment. — These were various, and prosecuted with 
American energy, but none proved satisfactory. In the beginning the con- 
dition was often not unlike that of a patient in the paroxysm of a malig- 
nant intermittent. The object was to excite reaction. To that end exter- 
nal and internal stimulation was employed, but with little or no success. 
Others, as Dr. Ames, bled copiously without regard to the state of the 
pulse, but it did not rise, and no direct benefit resulted from the loss. 
These were called congestive cases, and generally proved fatal. When the 
arterial excitement was that of reaction, and the pulse not less than the 
headache and other symptoms seemed to demand bloodletting, the loss of 
thirty, forty, and even eighty ounces of blood in twenty-four hours, seemed 
to produce little effect, either good or bad. Dr. Boling, in the same epi- 
demic, took from a girl only fifteen years of age, forty-eight ounces by cups, 
and twenty-six by the lancet in eighteen hours. In another case Dr. Ames 
drew forty-four ounces at a single bleeding, and although the pulse was en- 
feebled by it, and the face was made pale for several days, the excruciating 
headache a was hardly at all relieved/' In another case, seeming urgently 
to demand it, the loss of blood was such as to produce a great tendency to 
syncope, which continued for some time, yet " no relief whatever was ob- 
tained from it." On the whole, however, Dr. Ames is of opinion, that 



1 



762 THE PRINCIPAL DISEASES OP THE 

" prompt and free bleeding in the early stages" gained time for " other 
remedies more obviously beneficial to produce their effect. " In vigorous 
constitutions Dr. Hicks at the onset of the attack sometimes found blood- 
letting advantageous, yet it was generally unsuccessful. Dr. White tried, 
but abandoned it. Dr. Gray never employed the lancet, but was told by 
others that it invariably proved injurious. Dr. Chester employed cupping, 
but not bleeding. Dr. Love sometimes bled, but found no benefit from it. 
Dr. Fenner did not resort to the lancet, but found cupping useful. Dr. 
Scruggs both bled and cupped without a satisfactory result. Dr. Richard- 
son did not bleed. This abstract shows that the greater number of those 
who saw this disease were deterred by the symptoms from bleeding; and 
that those who thought it admissible or demanded were disappointed in its 
effects. We are thus taught (not a new but) the important therapeutic 
truth, that there are combinations of inflammation and fever, over which 
the loss of blood exerts but little control. In this instance the failure har- 
monizes fully with the state of the circulation, as indicated by the symp- 
toms. Yet in this and many other fevers a single bloodletting, although 
not curative, is, in certain cases, indirectly beneficial, by diminishing ple- 
thora or increasing the susceptibility of the system to medicine. 

As the bowels were generally costive, cathartics seemed necessary. Dr. 
Ames employed them to a limited extent, and they were sometimes useful ; 
but he saw two cases in which their drastic operation was injurious. Dr. Hicks 
gave a mercurial cathartic after venesection in the beginning of the disease, 
with decided benefit, but does not seem to have repeated it. Dr. White 
found purging of little value. Dr. Gray purged but little. He saw con- 
vulsions and syncope follow on the operation of ten grains of calomel. On 
the whole I may say, that although the state of the bowels seemed to de- 
mand free purgation, so beneficial in sporadic cerebro-spinal meningitis, 
cathartics were administered so sparingly, that a fair trial of their powers 
was scarcely made. This, perhaps, arose from observing no benefit from 
the first, or from the opinion prevalent throughout the South in latter years, 
that copious purging is unsafe in all its fevers. Should this disease prevail 
in higher latitudes, purging would probably be found both safe and benefi- 
cial. Emetics are mentioned as having been employed, but with no com- 
mendation. 

Calomel, with Dr. Ames, was a favorite remedy. There was no tendency 
to diarrhoea, and the medicine never produced intestinal irritation ; he fre- 
quently employed mercurial inunction at the same time. In a few instances 
an early salivation had no effect in arresting the disease; in others no con- 
stitutional effects were produced, either from want of time or of suscepti- 
bility to the action of the medicines. Still, they were regarded as more 
beneficial than bloodletting. Dr. White tried " mercurials" without any 
satisfactory results. Dr. Frenner gave large doses of calomel and camphor 
with good effect. In general the " mercurial practice" does not appear to 



INTERIOR VALLEY OF NORTH AMERICA. 763 

have been adopted to much extent, and the chief testimony as to its success- 
ful employment is that of Dr. Ames, which cannot be regarded as decisive. 

Carbonate of potash was administered by the gentleman just named, in a 
number of cases, mostly not the malignant, with effects which give him 
much confidence in its power. He had previously given it with advantage 
in hydrocephalus. His dose in the epidemic was from ten to fifteen grains 
every two hours to adults, and from three to five grains to children, accord- 
ing to their ages. As he used " other remedies of the most energetic kind" 
at the same time, it is difficult to estimate the value of the alkali. 

The antimonial preparations were but little employed, but Dr. Hicks 
speaks highly of the following mixture : — 

R. — Pulverized Camphor, . • . . . gj. 

Tartarized Antimony, . ♦ . . gr. ii. 

Mucilage of Gum Arabic, .... ^vj. 
Triturate together, and give half an ounce every two hours. 

The sulphate of quinine was employed to some extent by Dr. Ames, and 
condemned; but in the most remitting cases it occasionally did good. Dr. 
Hicks has said nothing of it, and Dr. White nothing in its favor. Dr. 
Chester found it fail, even when the fever was " regularly intermittent." 
Dr. Doling saw it succeed in two intermittent cases which were not very 
violent, while it failed in others of a graver character. In certain cases 
which seemed to demand it, Dr. Love found it injurious. Other physicians 
say nothing of it, or nothing to vary the conclusion that it was not adapted 
to the cure of this disease. 

But little opium was used, and the reports concerning it are generally of 
a negative character, or, with a few exceptions, against it. 

Cupping and blisters were extensively employed over the head and whole 
length of the spine ; but no case is mentioned in which decided abatement 
of the pain or tetanic spasms followed their operation, except by Dr. Ames, 
who saw the headache greatly relieved by blisters when venesection had 
failed. He also saw sinapisms and oil of turpentine do good service in several 
cases. 

Cold water to the head and spine is mentioned by some, but without any 
estimate of its value. The full effect of cold applications over the spine 
was not, I think, ascertained. 

During convalescence, Dr. Hicks found the following formula beneficial 
in removing the " inertia of the nervous system:" — 

K. — Iodine, ...... gr. viii. 

Iodide of Iron, . . . . . • BJ ♦ 

Hydriodate of Potash, . „ . . gij. 

Syrup of Sarsaparilla, ..... ^iv. 

Mix, and give a teaspoonful every four hours in a little water. 

The efficacy of every mode of treatment in this disease seems to have 



764 THE PRINCIPAL DISEASES OF THE 

been small. The ratio of its mortality cannot be calculated. At Mont- 
gomery, Dr. Ames, estimated it at sixty per cent, of the malignant cases j 
but the proportion of these to the whole number is not given. In some 
other localities, as on the Mississippi, among the troops, it was still greater. 
In some country settlements, where the number of patients was compara- 
tively few, nearly all died. 

In conclusion, I may say a few words on the European treatment of this 
malady; and a few will be sufficient, for it was substantially the same 
which has been detailed, and the results were equally unsatisfactory. The 
testimony in favor of opium and quinine, however, and especially of the 
former, is more favorable there than here, and both appear to have been 
more extensively administered, — bloodletting having been premised. 



CHAPTER X. 

INFLAMMATIONS OF THE ORGANS OF MOTION AND OF SPECIAL SENSE- 
RHEUMATISM— OPHTHALMIA 



SECTION I. 

RHEUMATISM. 

I. Relations with Myelitis. — "We may pass from myelic or spinal 
inflammation to articular rheumatism over two facts which seem to connect 
them together; or, at least, to establish a relation between them. In October, 
1844, a gentleman, twenty-seven years of age, who had never experienced 
an attack of rheumatism, fell from a considerable height on his back, upon 
a hard inelastic floor. The concussion was so great that it was with some 
difficulty he could walk from the gymnasium. During the following winter 
he experienced several attacks of thoracic stricture and dyspnoea, sometimes 
simulating globus hystericus, and, although he "kept about," his limbs 
were weak. In the following June, after standing on his feet most of the 
day, and lifting a number of articles, he was seized at night with severe 
pain in one of his legs, and found difficulty in leaving his chamber in the 
morning. Before the following night, he was compelled to lie down, from 
excruciating pain in both legs and one arm. Almost immediately it became 
concentrated in his ankles and feet and one wrist and hand, the whole of 
which swelled, reddened, stiffened, became exquisitely tender, and suffered 
intense pain, — displayed in fact all the symptoms of acute rheumatism, and 
confined him to the bed for three weeks. I cannot doubt that this articular 
inflammation was occasioned by the spinal concussion. 

The other fact to which I referred is recorded by Dr. Gray and Dr. Love 



INTERIOR VALLEY OP NORTH AMERICA. 765 

in their respective histories of epidemic cerebro-spinal meningitis, both of 
whom saw pain, tenderness, and swelling of the joints of the extremities, 
which, like metastatic rheumatism, frequently change their place. 

These facts, which increase the evidence, collected by modern observation 
of the spinal or myelic origin of articular rheumatism, will at least show 
that there is no nosological impropriety in introducing it immediately after 
inflammation of the cerebro-spinal axis. It would be waste of time to go 
into the symptomatology of this well-known disease, and I shall therefore 
consider it under other aspects. 

II. Etiology. — 1. A hasty generalization might declare all rheumatic 
inflammation of spinal or myelic origin, and thus make it a secondary affec- 
tion ; but such, I take it, is not the fact. Every physician has seen it 
limited to a single joint, and that, in many cases, one which has been 
sprained or bruised at some antecedent period. It is equally well known 
that severe attacks have continued for a loug time without the least mani- 
festation of spinal disease, unless, by a petitio principii, we declare the arti- 
cular disease to be such a manifestation. Again, the tissues which are most 
affected in rheumatism are not most endowed with nerves. Lastly, there 
seems from the products of rheumatic inflammation to be a peculiar humero- 
solid diathesis, a condition of the blood, sui generis, and not a mere lesion 
of spinal innervation. We may conclude, then, that spinal or myelic 
inflammatory irritation is but one of the causes of rheumatism. 

2. There is no doubt, I think, that some families are more subject to 
rheumatism than others living under the same circumstances, that, like 
gout, it is, in fact, to a certain moderate degree, hereditary. The child is 
born with a predisposition, and slight exciting causes bring on the inflam- 
mation. It may be said that this predisposition involves the spinal cord, 
and I cannot prove that it does not. At this moment, however, we are but 
contemplating the historical fact of a transmitted liability to the disease. 

3. Childhood and youth predispose to rheumatism. What are called 
" growing pains," for which our children get so little sympathy, are morbid 
sensibilities and achings of the periosteum of the long bones, and occur in 
the legs more than the arms, from their being more violently exercised. 
Such affections are but tendencies to rheumatic inflammation. The attacks 
of the disease are often transient in childhood, and are soon forgotten ; but 
I have so often found by retrospective inquiry that the man affected with 
rheumatism, or a lesion of the valves of the heart, had experienced one or 
more attacks in boyhood, that I cannot doubt the great liability of that 
period to the disease. At whatever age it may first occur, its recurrence is 
to be expected. Every attack, indeed, seems to prepare the way for another 
under exciting causes of a still slighter character. 

4. The male sex is more subject to rheumatism than the female ; but this 
may not be constitutional, for men are more exposed to certain well-known 
or reputed causes than women. 



766 THE PRINCIPAL DISEASES OF THE 

5. Rheumatism, like gout ; may be produced by a full diet with stimu- 
lating drinks. Some of the most violent and obstinate cases I have ever 
seen were in gormandizers, especially when they drank whiskey at the same 
time. It is certainly remarkable that gout should be so rare in this coun- 
try, the population of which has been so largely derived from England. I 
have seen many cases of what might be called rheumatic gout, but in fifty 
years have not seen five cases of gout answering to the description of that 
malady as given by Sydenham, a fact the more remarkable as the people of 
England two centuries ago lived on a comparatively simple diet, with habits 
of life and pursuits not very different from those of our Interior Valley. 
According to the great observer just quoted, those most liable to gout were 
men of a a plethoric, moist, and lax habit of body, and withal of a strong 
and vigorous constitution, and possessed of the best stamina vitee."* This 
I think, is a comprehensive account of the true English temperament; but 
immigration to this country has modified it, and diminished the liability to 
that disease. There may be another reason still. Gout is not only the 
disease of " high livers," but of men who at the same time are of cultivated 
intellect, and pass their time in study, leisure, or sensual enjoyment. Now, 
this class is very small, even at the middle of the nineteenth century, in what, 
as compared with Europe, may be called, as heretofore, the Backwoods. 

6. Over exertion of the back and limbs, contusions of the joints and 
sprains, are causes generally predisposing, sometimes exciting, of rheuma- 
tism. This is one of the reasons why the disease prevails so much in the 
country, and among the laborious classes of our river men. The stretched 
or bruised fibrous structures of the joints very slowly recover their normal 
condition, and often remain permanently weakened, and susceptible of in- 
flammation. Blows on the back, moreover, and heavy liftings, are preju- 
dicial to the muscles and their fascias, the ligamentous, and cartilaginous 
tissues of the spine, and the medullary cord itself; whereby lumbago, scia- 
tica, and secondary articular rheumatism are, so to speak, incubated, if not 
(without the aid of other causes) brought forth. 

7. The relations between rheumatism and climate have at all times been 
admitted. Mere vicissitudes of temperature may produce it ; but changes 
in the humidity of the atmosphere, especially its saturation with moisture 
when the thermometer stands low, are still more injurious. The approach 
of rain or snow often brings on an attack. Exposure to falling rain, or to 
the night air without sufficient protection of the surface of the body, is 
equally prejudicial. Even in our hottest latitudes this influence is ope- 
rative, and hence rheumatism is as common among the seamen of the Gulf 
of Mexico, and the soldiers garrisoned on its coasts, as among the watermen 
and troops of the Great Lakes fifteen or twenty degrees further north. To 
these climatic influences we may chiefly ascribe its prevalence among the 
negroes of the South and the Indians of the West. The agency of climate 

*Wallis's Sydenham, yol. ii. p. 182, London, 1788. 



INTERIOR VALLEY OF NORTH AMERICA. 767 

in the production of the first attacks is not always recognized, but when the 
disease has assumed a chronic and relapsing form, the joints which have 
often suffered frequently give premonition of atmospheric changes in ad- 
vance of our hygrometers and barometers ; a fact which suggests that the 
system of a rheumatic may be affected in an occult manner by the electri- 
city of the air. 

8. The relation between rheumatism and autumnal fever, or its cause, 
must not be overlooked. The localities which breed the latter are generally 
infested with the former ; but the moisture which is necessary to the pro- 
duction of the cause of that fever may be the direct cause of the rheuma- 
tism. Yet, admitting this, enough of pathological relation remains to fix 
our attention. The rheumatism which prevails in what is called malarial 
situations is less acute than in other localities, and more apt to be compli- 
cated with gastric and especially biliary derangements. But what is still 
more to the point, its subacute, chronic, and relapsing forms are apt to 
assume more or less of an intermittent type, and demand a treatment simi- 
lar to that for protracted intermittents. And this reveals to us a patholo- 
gical relation between rheumatism and certain neuralgias.* There is not 
in fact any line of distinctive diagnosis between them. They are seated 
apparently in the same tissues, the pain is of the same kind, in many cases 
they are respectively productive of simple, temporary hyperemia, and they 
are relievable by the same treatment. Rheumatism then becomes a neu- 
rosis. 

9. I must not omit a passing (though not very satisfactory) notice of 
another combination which may be as well introduced here as elsewhere. 
Since the year 1849, for the last two years, there has prevailed in Cincin- 
nati and other places in the Interior Valley, a sub-epidemic phlegmonous 
inflammation, in the form of paronychia, furunculus, and carbuncle. In 
less than a year I saw in consultation three fatal cases of the last, a greater 
number than I had ever seen in our city before, and the first two were 
common and obstinate beyond all precedent. They were, I think, more com- 
mon among the male than the female sex, but of the victims of carbuncle, 
two were women advanced in life. When this malignant phlegmonous 
atmospheric constitution was upon us (which is even down to the present 
time), cases of erysipelas were so common as to indicate an equal tendency 
to that disease. Thus, while a young man was fatally ill of that disease, 
his blood cousin of the same age was suffering under a series of most pain- 
ful paronychias, the last of which was immediately succeeded (without any 
obvious cause) by an attack of violent acute rheumatism in the left hip and 
right hand, and his father, who had been physician to his cousin, was mean- 
while seized with erysipelas. I would not generalize from a single case, 
yet it does seem as though the rheumatism was connected in origin with that 
occult constitution of the atmosphere which gave birth to the paronychias, 

* See Book ii. Part i. Ch. x. Sect. vii. 



768 THE PRINCIPAL DISEASES OF THE 

carbuncle, and phlegmonous erysipelas; to which I may add, that about or 
soon before the same period, suppurative inflammation of the cerebro-spinal 
membranes was, as we saw in the last chapter, prevalent in various parts of 
the Valley, and attended, in several persons, with rheumatic pain and swell- 
ing of the joints. 

10. Gonorrhoea sometimes becomes a (pathological) cause of rheumatism. 
This complication must be rare, however, for I have met with but one well- 
marked case. The late Professor Richardson, of Transylvania University, 
informed me that he had seen several, and they all like my own proved 
uncommonly obstinate. It commenced while the patient was still laboring 
under the first disease; attacked the larger joints, with the usual pheno- 
mena, and changed from one to another. I cannot concur in the opinion 
that it is most frequent in those who are treated with balsam copaivse, 
having seen a great number of patients take that medicine without super- 
vening rheumatism ; nor do I suppose that it depends on stricture, which 
was certainly not present in the case to which I have referred. It occurs, 
I presume, in those who have a rheumatic diathesis, on which the gonor- 
rhoea merely acts as an exciting cause. 

III. Pathology. — We are scarcely at liberty to regard rheumatism as 
one of the simple phlegmasia, consisting in an antecedent inflammation of 
a joint and a consequent fever, such as might result from mere external vio- 
lence, for in many cases the fever precedes the inflammation ; the hyperinosis 
of the blood is out of all proportion great, compared with the extent of the 
inflammation, the excretions from tbe skin and lungs are frequently sour 
and offensive ; deposits of a peculiar kind are made in the inflamed part ; 
the inflammation frequently changes its place, or appears in several at the 
same time ; lastly, the antiphlogistic treatment exercises less control over it 
than over that which follows mechanical injury. All this indicates a quasi 
peculiar, phlogistic diathesis. To what extent or in what manner the in- 
nervation is affected in this condition of the system, I do not pretend to un- 
derstand. The general integrity of the intellectual functions suggests that 
the brain is not involved, but we may perhaps admit that the spinal cord 
and the excito-motory nerves are in many cases implicated; that this may 
be one cause of the metastasis so characteristic of this disease, and of the 
rigid muscular contractions, which so often lead to permanent infirmity, not 
to be accounted for, in many cases, by the tophaceous deposits around the 
joints. 

As to the state of the blood we perhaps know but four facts : first, the 
decided increase of fibrine beyond what takes place in most phlegmasise. 
Second, the diminution of corpuscles, greater I think than can be accounted 
for by the loss of blood. Hence the prominence and cupping of the bufly 
coat, and the comparative smallness of the clot ; phenomena which I recol- 
lect to have noticed long since, and the reality of which has been lately es- 
tablished by experimental hematologists. In the opinion of Simon, the red 



INTERIOR VALLEY OF NORTH AMERICA. 769 

corpuscles are the source of uric acid, the fatty acids, including the choleric 
of the bile, and the lactic acid of the sweat. If this be true, we may un- 
derstand why in rheumatism, when a part or the whole of these acids (nor- 
mal elements of the blood), are augmented, there may be abnormal diminu- 
tion of the corpuscles. Third, as a negative character, a reduced tendency, 
as compared with many of the phlegmasise, to the production of pus. I am 
aware that the variety of suppuration in this disease is generally ascribed 
to the inflammation being seated in the fibrous, ligamentous, and synovial 
tissues, but in every case it also extends to the surrounding and connecting 
areolar texture, and yet suppuration but seldom occurs. Fourth, an acid 
development in the blood. 

When acute rheumatism abates under a copious perspiration, the secreted 
fluid is often, if not always, acid beyond the normal degree, and the odor 
gives in many cases evidence of the presence of acetic acid. We can scarcely 
suppose this to be formed in the skin, through which it is but eliminated, 
especially when we recollect that the same phenomenon often attends the 
conclusion of a fit of dyspepsia. If not developed in the blood, it passes 
through that fluid to the cutaneous and pulmonary emunctories. But the 
quantity of lactic acid, a normal element of the blood and sweat, is accord- 
ing to Simon usually increased in the perspiration in cases of rheumatism,* 
showing that it must be augmented in the blood. It has been lately affirmed 
by Dr. Grarrod,j" that in acute rheumatism, there is no increase of uric acid, 
another normal ingredient of the blood, but this merely negative testi- 
mony is opposed by the positive results of the experiments of Dr. Macla- 
gan,J who in several cases, detected a great increase of that acid in the blood 
and a diminution in the urine. Thus the attempt to establish, on the pre- 
sence or absence of this acid, a distinctive diagnosis between gout and rheu- 
matism, was premature. It must be admitted, however, that the uric acid 
diathesis is far more evident in gout than in rheumatism, and hence the 
great frequency of tophaceous deposits of urate of soda in the one, and 
their variety and limited volume in the other disease. It may be perhaps 
that while the gouty diathesis is characterized by uric acidity, the rheumatic 
is marked by the lactic and acetic, without exclusiveness in either. How- 
ever, other acids, or their bases, exist in healthy blood, and being increased 
in quantity, may contribute to the rheumatic if not to the gouty diathesis; 
these are, the fatty, as the oleic, margaric, and stearic. In one case of acute 
rheumatism, Simon found the fat of the blood " sensibly increased." The 
relations of all these acids to each other, and to the other elements of the 
blood, is too obscure and subtile to be dwelt upon by the mere physician, 
who may admit, however, that in the metamorphosis of the first formed 
elements, unknown disturbing influences may diminish the production of' 
one acid and increase that of another, whereby the acidulous diathesis may 

* Chem. of Man, p. 377— Phila. Ed. t Brathwaite's Retrosp., vol. xxi. p. 338. 

% Ibid. vol. xxv. p. 38. 

vol. ii. 49 



770 THE PRINCIPAL DISEASES OF THE 

present much chemical variation, in accordance with the diversities presented 
by the vital properties and functions of the solids in gout and rheumatism. 
The acetic, lactic, and fatty acids composed of carbon, hydrogen, and oxy- 
gen, in varying proportions, differ from the uric, which contains a fourth ele- 
ment, nitrogen. Now we may assume that as the kidneys are the natural 
outlet of the nitrogenized excreta of the blood, the skin and lungs, known 
to excrete lactic, acetic, carbonic, and fatty acids, may constitute the natu- 
ral emunctories of the non-nitrogenized excretions of the blood. Thus we 
may hypothetically recognize an acidulous diathesis of one kind for rheu- 
matism, of another kind for gout, and of another or mixed kind for those 
cases which seem to lie intermediate, and are called rheumatic gout. That 
we know much more of the uric acid diathesis than of the other, results 
from the greater normal production of that acid, and its excretion through 
a single channel, while the other acids pass off through the pores of an im- 
mense superficies, and can with great difficulty be collected in quantities suf- 
ficient for successful examination. Then, again, the uric acid forms with 
soda (the chief alkali of the blood) an insoluble salt which is infiltrated into 
the inflamed part, and may be analyzed, but all the non-nitrogenized acids 
form with that base soluble salts which are not deposited, and hence acidu- 
lous blood in rheumatism (if uric acid be not present), may not be followed 
by articular concretions ; though when present to a limited extent, small 
deposits of urate of soda may take place, which is what we find in some 
cases of that disease. These speculations connect themselves with certain 
admitted remote causes of the two diseases. Thus a full diet of nitrogen- 
ized food, warm clothing, which increases the secretion of the skin, while it 
diminishes that from the kidneys, and bodily inactivity, which lessens the 
excretion, and perhaps also the secretion of urine, are highly favorable to 
the retention and absorption from the bladder, and the consequent accumu- 
lation in the blood, of uric acid, and of course they promote the diathesis 
which is present in gout.* On the other hand the less nitrogenized diet, 
deficient clothing, and undue exposure of the skin, may favor the development 
of the other acids, and certainly do impede their elimination through the skin, 
and favor their accumulation in the blood. 

The acids we are now considering, no doubt have their origin or increase 

* Bodily inactivity leads to retention of nrine in the Madder, whence, from some facts which have 
fallen under my observation, I am disposed to believe a portion of it is absorbed. But the same inac- 
tivity perbaps diminishes the secretion of that fluid, by withholding from the kidneys that mechanical 
stimulus, which comes from the strong contraction of the psoas muscles when in active exercise. It is, 
I suppose, a physiological law, that the agitation of a secreting organ by that portion of the muscular 
system which can act upon it promotes secretion. Thus the secretion of bile and gastric juice is increased 
by exercise, the neglect of which sometimes brings on jaundice and dyspepsia; and the sero-mucus of 
the bowels is increased by the same means, whereby the formation of scybala? is retarded. Even the 
salivary glands are stimulated in the same manner. The increased secretion of saliva during mastica- 
tion, is generally ascribed solely to the stimulus of food, when applied to the extremities of efferent 
ducts ; but the simple motion of the jaws, when the mouth is empty and the lips are kept closed, will 
soon fill it with saliva and mucus. Hence patient mastication of hard and tasteless biscuit will convert 
it into a pulpy mass. 



INTERIOR VALLEY OF NORTH AMERICA. 771 

in many cases, in abuses of diet, and disordered states of the chylopoietic 
functions; but, in others, they may arise from disturbance of assimilation. 
The former occur in the chyle and venous blood, the latter in the arterial 
blood, the various tissues, and the organs of sanguineous excretion. To these 
disturbances of chylification and assimilation, disordered states of the in- 
nervation may contribute, and hence a rheumatic diathesis includes lesions 
of both the solids and fluids. 

IV. Anatomical Lesions. — Partial or perfect immobility of the joints 
may follow on rheumatism. For awhile after the inflammation has ceased, 
there may be great stiffness of the joint, with limited motion. It is com- 
mon to regard this as resulting from an undefined lesion of the articulating 
ligaments, but I would refer it in part to an extension of the inflammation 
to the muscles which are left with a disposition to continued and perma- 
nent contraction. In many of these cases there is, I presume, a deposition 
of lymph in the intermuscular substance, which, by its spontaneous con- 
traction, contributes to the rigidity and shortening of the muscles. They 
seem in fact to undergo an organic change. In gout, the stiffness or immo- 
bility is commonly the consequence of the deposition of urate of soda, but 
it must be admitted that in rheumatism this seldom takes place. When the 
inflammation attacks the synovial membrane of an enarthrodial joint, as that 
of the hip, the filling up of the socket by effused fluids may occasion spon- 
taneous dislocation ; and when it attacks the articulating or cartilaginous 
surfaces, adhesion and permanent anchylosis may be the result. When the 
inflammation attacks the sclerotic coat of the eye (rheumatic ophthalmia), 
if the cornea should be involved, as sometimes happens, ulcerative inflam- 
mation may discharge the humors of the eye; but more frequently the 
inflammation extends to the choroid and retina, giving rise to amaurosis, 
with tuberous deformity of the eyeball. 

The most serious lesions from rheumatism are found in the heart, espe- 
cially in the valves of the left side, which, becoming loaded with fibrine, 
move with difficulty, and generate a rasping or purring sound. From this 
impediment to the circulation, result hypertrophies, and ultimately death 
itself. I have seldom heard this sound in a young person (not chlorotic) 
without learning on inquiry that articular rheumatism had previously ex- 
isted. In this country, these lesions are far commoner than those of the 
eye, and often remain undetected for a long time. 

It is not necessary that the inflammation should be of the acutest kind to 
produce permanent infirmity. On the contrary, we frequently meet with 
ingravescent articular rigidity in cases of subacute or chronic rheumatism. 
The extent to which permanent rigidity and apparent anchylosis may take 
place, is illustrated by the following case, which, through the politeness of 
Dr. Rosa, of Painesville, on the shores of Lake Erie, I had an opportunity 
of examining in the year 1842. The history of the case was taken down from 
the recollection of the patient, his mother, and Dr. Rosa, who had been his 



772 THE PRINCIPAL DISEASES OP THE 

physician for several years. The examination was made by myself, and 
carefully recorded at the time. 

Valentine Perkins, aged twenty-five years, was born in Ontario County, 
N. Y., and was brought to the neighborhood of Painesville when seven years 
old. In the summer, when eleven years of age, having previously enjoyed 
good health, and being a lively and active boy, he was, without any known 
cause, seized with a swelling and slight pain in his left knee. He was still 
able to go to school. The pain in the winter was worse ; but next spring 
and summer went to school, and was able to work. In the following winter 
the pain was worse, but did not require him to lie by. In the spring after 
this winter, was taken with pain and swelling in his right knee. About this 
time, the left became so loose and relaxed that it seemed as though it would 
slip out of joint. Soon afterwards it began to "draw up/ 7 and in the fol- 
lowing or third fall and winter, it became flexed nearly at right tingles 
and fixed. The right knee went through precisely the same course, 
with greater pain than the left, and was at length anchylosed. The right 
ankle was next attacked, and experienced the same fate j then the left elbow ; 
then the wrist of that side. All suffered pain and swelling, followed by 
great relaxation and looseness, succeeded by anchylosis. The elbow is 
flexed ; and the hand rotated into pronation, or towards the thumb, where 
it remains immovable. While these derangements were in progress, the 
same morbid action attacked his neck. The pain and swelling were mode- 
rate. The relaxation became so great that he could not hold up his head. 
Stiffness then followed, with his face inclined forwards, downwards, and 
a little to the left where it remains permanent. After this, the left ankle, 
and then both hips became the seat of the same series of morbid changes, 
and are all firmly anchylosed. Subsequently his whole spine stiffened, with 
a little side curvature; his ribs became immovable; his jaws became fixed, 
and, in short, of all his articulations, the following only retain a capacity for 
motion to a limited extent : — the shoulders admitting a little rotation of the 
arm ; his toes and the fore and middle finger of his right hand. Eight 
years ago, and ten after the first attack, his left, and the next year his 
right eye became inflamed. They were red, and discharged hot water. In 
a few months, blindness ensued. At this time the balls are sunken, reduced 
in size, and irregular in shape. The cornea of each retains its transparency, 
but is flat and in contact with the iris, the pupil is much contracted and 
plugged up with false membrane. On the top of his head, there is a broad 
exostosis, and the scalp over it is verrucous or covered with white warts. 
He experienced pain in these parts before these anatomical changes occurred. 

His fingers are red, soft, and atrophied. All his nails have suppurated 
or sloughed off, except that of the left thumb and right little finger, and in 
their place have shot out horny, rough spurs, or conoidal excrescences, at 
right angles from the places covered by the nails. His toe-nails remain. 



INTERIOR VALLEY OF NORTH AMERICA. 773 

His muscles, except those of his face, and the trunk of his body, are 
greatly atrophied, and feel soft. His face, allowing for the loss of eyes, 
looks pretty well — has indeed a tolerably healthy and intelligent expression. 
His appetite is good. He generally has two alvine evacuations in twenty- 
four hours. His urinary discharges are regular. His pulse is firm and 
regular — 108 in a minute. 

As his ribs are immovable, inspiration is effected by the depression of his 
diaphragm. For the last two years, the pain which he experiences is mostly 
in his head, but shifts and wanders. His appearance was cleanly — mother 
a poor widow — cheerful. 

V. Constitutional Treatment of Acute Rheumatism. — 1. The 
period of life in which this disease generally occurs, the constitutions of 
those most subject to it, the fever, the force and frequency of the pulse, the 
known hyperinosis of the blood, and the acute pain in the affected part, 
unite in suggesting an active antiphlogistic treatment. In common with 
others, I have been accustomed to employ it, and cannot believe that it should 
be omitted ; yet I have rarely seen the disease cease under its influence. 
In early life, under the teachings of that earnest and eloquent advocate of 
liberal venesection, Dr. Rush, I bled many patients, till the crassamentum 
of the blood was strikingly reduced ; but the disease continued, and the 
buffy coat, in part, no doubt, from the loss of the red corpuscles, seemed as 
thick on the first as the last clot. Nevertheless, I am far from believing 
that bloodletting is not necessary in such cases, for while the vessels are 
full, and the power of the heart great, the system is not susceptible to the 
impress of therapeutic agents. I have seldom resorted to local bleeding, 
because inflamed joints are generally too tender to bear cups, and leeches in 
this country have always been too scarce. 

2. Emetico-cathartics, preceded by venesection, are frequently of more 
immediate benefit than the loss of blood. They are especially required in 
patients who are given to gormandizing. In all such, a thorough evacuation 
of the stomach and bowels is generally followed with mitigation of fever, 
swelling, and pain. The dose may be repeated with advantage, and the 
purging as a means of depletion and revulsion, kept up for some time. It 
cannot be doubted, I thiuk, that vomiting carries a beneficial influence into 
the whole nervous system, while it promotes a determination to the skin, 
than which nothing is more beneficial in this disease. Many cases of rheu- 
matism, in autumn and winter, occur in persons whose biliary systems had 
been deranged in the previous summer, and free vomiting is the more bene- 
ficial on that account. Antimonial emetics are the best; and no compound 
is superior to Rush's powder, composed of a sixth of a grain of tartarized 
antimony, a grain of calomel, and ten grains of nitre, which will both vomit 
and purge. Another appropriate formula is calomel and jalap with tartar 
emetic. Another, calomel followed with compound powder of jalap; or 
jalap and nitre. The last-named salt has recently been advised in large 



774 THE PRINCIPAL DISEASES OF THE 

doses as a sedative in this disease. I have not used it in that manner, but 
have long regarded it as beneficial in combination with the medicines just 
mentioned. 

3. Of antiphlogistic alterants, the best, I think, is the compound first 
mentioned above. Given every two hours, it will soon cease to vomit or 
actively purge the patient ; but the inflammatory excitement is lowered, and 
as the respective ingredients make their specific impressions on the system, 
the rheumatic action is sometimes superseded. In general this course may 
be pursued several days before the mouth will be affected, though calomel 
administered with tartar emetic salivates earlier than when given alone. 
In all severe cases, it should be continued until its effect on the mouth is 
perceptible, but no longer. I cannot affirin that a mercurial action is as 
beneficial in muscular, fibrous, and ligamentous inflammation, as it is known 
to be in serous, yet of its benefits there is no doubt, and in localities where 
the chylopoietic organs are disordered, it is especially applicable. 

4. But something else than reducents and sedative alterants is necessary, 
even while we are still employing these. In rheumatism we have an 
exalted state of sensibility and muscular contractility which must not be 
overlooked. Hence the necessity for the early administration of opium. 
Even after the first copious bleeding and the first emeto-cathartic, the patient 
should be composed at night with a full dose of opium, and the action of 
his bowels suspended. When he has been vomited during the day, it is 
best to give the opium without a nauseant ; but otherwise he may take 
Dover's powder, or laudanum with wine of ipecac. In this manner his 
nervous system is soothed, and his pain abated, the irritability of his heart 
diminished, and an early diaphoresis excited. If he labor under any hepatic 
derangement, calomel may be combined with the powder. The value of 
opium in chronic or neuralgic rheumatism is, I think, generally admitted; 
but it has not always been given early and liberally in the acute forms, because 
the activity of the pulse has seemed to contraindicate its use. That activity, 
however, depends largely on the modified contractility of the heart, and after 
depletion is best subdued by opium, which may be given (whatever may be 
the preparation) in quantities extending from one to three or four grains in 
a single night. As opium in some persons diminishes the secretion of urine, 
it might be supposed to retard the elimination of uric acid from the blood; 
but if the nitrate of potash, or some other diuretic, be given at the same 
time, the action of the kidneys will be maintained. We must recollect, 
however, that the lactic and acetic acids, not less than the uric, appear to 
be present in rheumatism ; that they pass off by the skin, and that while 
opium lessens the flow of urine, it increases that of perspiration, under which 
the disease sometimes ceases. 

5. As a sedative, alterant, and diuretic, in acute rheumatism, colchicum 
has been lauded by many physicians. Much of the benefit attributed to it 
is supposed to come from its promoting the excretion of uric acid from the 



INTERIOR VALLEY OF NORTH AMERICA. 775 

blood by increasing the secretion of urine. In cases attended with that 
diathesis, it no doubt does good in that way ; but it also acts beneficially on 
the nervous system and the heart. Yet, if I am not mistaken, its influence 
over rheumatism is much less than over gout. I have certainly seen rheu- 
matic fever and inflammation survive the obvious and powerful impress of 
that medicine on the body. The best mode of giving it is in doses of two 
or three or four drachms of the wine with forty or fifty drops of laudanum, 
at bedtime. Thus administered, it often increases secretion into the bowels 
during the night and excretion from them the next morning, when it gene- 
rally does much good. Instead of this potion, I have used the formula of 
Dr. Scudainore,* but have not seen it as beneficial in rheumatism as that 
physician found it in gout. 

6. I have referred with approbation to the nitrate of potash in speaking 
of Dover's powder ) but must say that this refrigerant diuretic has, uncom- 
bined with other medicines, been liberally administered in acute rheumatism, 
not only with safety, but decided advantage to the patient. Dr. Bennetf 
has seen it given in a great number of cases, from six to sixteen drachms in 
the twenty-four hours, without the least gastric or renal irritation. It must 
however, be largely diluted to render it safe, — a mode of administration 
well fitted, moreover, to increase its efficacy. Its effects are a lowering of 
the force and frequency of the pulse, with increase of secretion by the 
kidneys, bowels, and skin. Thus, it fulfils the therapeutic demands of this 
case, by subduing or lessening inflammatory orgasm and depurating the 
blood. The tolerance, by the system, of these extraordinary quantities, 
reminds one of its tolerance of tartar emetic in pneumonia, and of opium in 
delirium tremens, and seems to show that it is well adapted to an acute 
rheumatic diathesis. I have not given it in the doses mentioned, but am 
disposed to regard the practice as worthy of trial. 

7. Dr. Buckler of Baltimore,! on the theory of urate of soda and lime in the 
blood, has proposed the administration of phosphate of ammonia, to effect a 
double decomposition, the results of which would be phosphate of soda and 
urate of ammonia, both soluble salts, which would pass off with the urine. 

8. Potash, or its carbonate, indifferently, has been strongly recommended 
by Dr. Furnivale,§ on the theory of an acid constitution of the blood. He 
does not affirm that it will subdue, but has seen it moderate the disease ; his 
great object, however, is to prevent inflammation of the endocardium and 
valves of the heart, which, he assumes, is chiefly occasioned by the state of 
the blood. He believes, moreover, that it keeps the fibrine in solution, and 
thus saves the valves from the sinister effect of its deposit upon them. I 

* R. — Magnesia, or its carbonate, from . . . . . gr xv. to gr. xx. 

Sulphate of Magnesia, from ..... 3J-t°oiJ- 

Acetous Tincture of Colchicum. from . . . 3J- *° 3'J- 

Mix. and dilute with any kind of aromatic water, as infusion of peppermint. This dose to he repeated 
every two. four, or six hours. 
f London Lancet, Feb. 1814. + Amer. Jour. Med. Sci. § Ibid. June, 1844. 



776 THE PRINCIPAL DISEASES OF THE 

have used it in a single case only. It did not seem to arrest the inflamma- 
tion of the joints, but the patient recovered without a metastasis to the 
heart. He advises that it should be given in moderate quantities in con- 
nection with colchicum. Dr. Wright,* also testifies, after an experience of 
six years, to the efficacy of this practice. He has used the carbonates of 
both potash and soda, preferring the former only when uric acid prevailed 
in the urine, as forming a soluble salt. He gives from eight to ten grains 
every two or three hours, in the camphor mixture of the shops, and at the 
same time directs warm bathing, general or topical, with a solution of the 
same alkali. 

9. It is rather perplexing, at least to the sciolist in chemistry, to find the 
very opposite treatment still more strongly commended. Dr. Atkinson tells 
us that he has used common vinegar with success, but prefers the distilled. 
His formula is below.f He does not propose this for young subjects; but 
for men of broken down constitutions affected with gastric derangements. 

Much greater stress has, however been laid on fresh lemon juice, com- 
posed of citric acid, or supercitrate of potash, malic acid, gum, and bitter 
extractive, dissolved in water. Dr. Bees, of London, first directed the atten- 
tion of the profession to this remedy in 1849, since which several physicians 
have reported in its favor, of whom its greatest advocate is Dr. Babington. J 
In his practice it did not increase the discharge of urine, but to some ex- 
tent that of perspiration. Its most obvious and constant effect was a dimi- 
nution in the force and frequency of the pulse, with a simultaneous abate- 
ment of febrile heat, swelling and pain. 

In six or eight cases, the average time of a perfect cure was little more 
than a week, the patients generally finding great relief within half that 
period. The dose was from four to six ounces, three times a day. When 
it did not keep the bowels open, a little rhubarb was administered. While 
Dr. Babington was making these trials in London, Dr. Pepper was engaged 
on the same subject in Philadelphia. § His dose was but half an ounce four 
times a day, yet the results of the administration were not materially diffe- 
rent from those of Dr. Babington. They are reported in fourteen cases, 
several of which, however, were unattended with fever. It was injurious in 
none, more or less beneficial in all but one, and promptly curative in the 
majority. The urine of most of the patients was examined and found either 
less acid or neutral. In none was it increased in quantity. In all the 
cases of Dr. Babington, and nearly all of Dr. Pepper, it was employed 
without previous bleeding or other preparatory treatment. 

A word on the modus operandi of lemon acid. The chemical therapeu- 

* London Med. Times for June, 1847. 

f R. — Acetic Acid, ......... gj. 

Tincture of Jalap, ....*.... min. xx. 

Tincture of Orange Peel, . . . . . . . . ^j. 

Camphor mixture sufficient to make a draught, to he taken three times a day. 
t London Lancet, November 1851. § Trans. Col. Phys., New Series, Vol. i. p. 124. 



INTERIOR VALLEY OF NORTH AMERICA. 777 

tists have argued that lemon juice produces its effects by conveying into the 
blood a minute quantity of potash to act as a neutralizer. Lemon juice, it 
is said, contains a supercitrate of that alkali ; which is converted into car- 
bonate, when the acid by digestive assimilation is metamorphosed into water 
and carbonic acid. The carbonate of potash thus formed, is supposed to be 
decomposed by the uric acid of the blood, and the urate of potash discharged 
off by the kidneys. But Prout has ascertained, that lemon juice contains 
less than two parts in a hundred, of both citric acid and potash, and, there- 
fore, we are not at liberty to believe, that an acid blood can be rendered 
neutral, by the doses of lemon juice which Dr. Pepper found efficacious. 
Dr. Keating, moreover, has seen crystallized citric acid, destitute of potash, 
equally efficacious with lemon juice in the treatment of rheumatism.* 
Thus, we are required, in the present state of our knowledge, to ascribe the 
beneficial effects of this acid to its action on the vital properties of the solids 
by which their phlogistic tone is reduced, and at the same time the peculiar 
rheumatic action is set aside. In other words, it appears to be an antiphlo- 
gistic alterant. 

VI. Topical Remedies. — I shall not dwell on the local treatment in 
acute rheumatism, from a conviction that until the constitutional dyscrasia 
is subdued or at least much abated, topical remedies are of little avail. 
When leeches can be obtained, they may be applied in numbers propor- 
tionate to the extent of the inflammation, after the momentum of the circu- 
lation has been weakened by venesection, and are well adapted to cases 
which do not seem to permit the lancet. When the inflammation is seated 
in the sclerotic coat of the eye, they may be used with great advantage. 
When the inflammation of the joint is deep-seated and the skin is not too 
tender for cupping, that may do more good, as more revulsive than leeching. 

Of applications to the affected part, water is one of the best. When the • 
fever is decidedly inflammatory and the heat intense, it may be cold. 
Under other circumstances, and especially when the system is irritable, it_ 
should be warm. In the latter condition, the joint should be coated with 
lint dipped in tepid water, and covered with oil or varnished silk, to restrain 
evaporation. According to Dr. Wright, already quoted, its efficacy is 
greatly increased by the addition of carbonate of soda; and the nitrate of 
potash has also been found beneficial. The effect of chloroform confined by 
impervious dressings remains to be ascertained. As to blisters, as long as 
the inflammation manifests a metastatic character, they had better be with- 
held. I have seen the disease leave the knee and fall on the hip-joint be- 
fore the plaster had been removed. But on this very account, when the 
disease attacks the heart, a larger blister should be immediately applied to 
the precordial region. The general excitement being reduced and the in- 
flammation fixed, a blister often does much good, especially if the patient 
be quieted during its operation by a large dose of laudanum or solid opium. 

* Trans. Col. Phys. New Series, Vol. i. p. 142. 



778 THE PRINCIPAL DISEASES OP THE 

An important part of the local treatment is the position of the affected 
limbs. The patient has an instinctive propensity to keep them flexed; 
which, in reference to the hands and arms is proper, but the legs should be 
kept extended, as stiffening, and even anchylosis of the hip or knee-joint 
may take place, producing irremediable deformity. 

VII. Chronic Rheumatism. — 1. Protracted rheumatism may be divided 
into subacute and neuralgic ; the former attended with manifest but mild 
inflammation, and occasional fever or febricula; the latter consisting in 
what may be called, for want of a better name, neuralgic aching with mus- 
cular weakness and flaccidity, or contraction and rigidity. Rheumatism 
through the entire scale, from acute inflammatory down to non-febrile and 
neuralgic, has pain for a constant pathological element. Fever, swelling, 
and redness, are attended with pain ; the fever maybe subdued and the 
pain continue; the swelling and redness may disappear, and the pain 
remain. This order cannot be inverted, and these facts teach us that a 
morbid state of innervation is the fundamental lesion in all grades and forms 
of rheumatism. It is this which constitutes them a single disease, with 
marked characteristics, as it respects the innervation, but diversified in the 
phenomena of the circulation. Chronic rheumatism, if febrile, must neces- 
sarily be subacute, but all subacute rheumatism is not necessarily chronic ; 
for although acute cases, brought down to subacute, often become obstinately 
protracted at that point of reduced excitement, yet we constantly meet with 
cases, mild at the beginning, which under treatment are speedily cured. 
This is not a distinction without a difference, nor a theory leading to no 
practical result; for the treatment of the two forms is not identical, although 
the degree of fever and inflammation may be the same in both. Thus, 
when the excitement in violent cases has, by depletion, been reduced to a 
subacute grade, further reduction is improper, but the case which begins 
with a corresponding degree of fever and inflammation, is most successfully 
met by that treatment. 

Bloodletting, purging, and abstinence, the greatest of our antiphlogistics, 
convert acute into subacute rheumatism, but cannot cure the latter, and 
pressed beyond a certain point, render the case protracted. They prepare 
the way for other remedies ; and it often requires much practical acumen 
to determine when the preparation is completed. In original mild or sub- 
acute rheumatism, a preparation of a similar kind but less in degree is gene- 
rally proper, and if we neglect it, and enter on their treatment with means 
adapted to the other class, we frequently find the fever and inflammation 
increased, or at least that no benefits result. All this resolves itself into 
the comprehensive law which gives to calomel, antimony, colchicum, opium, 
quinine, bark, and other active agents a higher and happier effect on the 
system immediately after bloodletting, vomiting, and purging, than before. 

Few of the cases we are now considering require or permit more than a 
single bleeding ; and the full effects of emetic and cathartic medicines are 



INTERIOR VALLEY OF NORTH AMERICA. 779 

obtained in a few days. Of formulae the best is the antimonial and calomel- 
nitrous powder of Dr. Rush, which, in the midst of adequate evacuation 
will generally excite a slight mercurial alterant action. Under this treat- 
ment many cases of primary subacute rheumatism are speedily subdued, 
but it often fails ; and then the case assuming a chronic character must be 
met by the same remedies as that which was originally intense. 

We have thus before us all cases of chronic febrile rheumatism ; and 
although febrile they are no longer to be met by depletion ; but are they, 
therefore, to be treated with stimulants and tonics ? It may be replied, 
that in proportion as the previous depletion has been copious and rapid, 
the medicine we administer may partake of that character, and in proportion 
as the fever is low, so that little but non-febrile neuralgia of the joints re- 
mains, stimulation is admissible. 

Some cases of this kind yield to a course of Dover's powder and calomel 
at night, continued till the mouth is slightly affected. Others give way to 
a fourth, sixth or eighth of a grain of tartar emetic, every two hours, with 
opium or laudanum at bedtime. The wine of colchicum, in small, repeated 
doses, with some preparation of opium at night, sometimes succeeds. Lemon 
juice, although better adapted to cases of high phlogistic action, has now 
and then been successful. It is to this grade of the disease that the hydriodate 
of potash is most appropriate. In the year 1843, I visited the hospital of 
the late Dr. Luzenberg, New Orleans, and found him exhibiting this medi- 
cine, in drachm doses, several times a day, to a number of rheumatics, and 
he assured me that its curative effects were most manifest. In my own prac- 
tice, however, they have not been so obvious. It seems probable that many 
of his cases were of gonorrhoeal or syphilitic origin. Bark, and the sulphate 
of quinine, must not be overlooked. Their best effects are obtained imme- 
diately after bloodletting, when the vessels have been suddenly unloaded 
and the excitement as rapidly lowered. Their chief adaptation, however, 
is to cases occurring in so-called malarial localities. This remark is equally 
applicable to arsenious acid, which, administered in connection with opium, 
sometimes proves beneficial. The latter medicine should indeed be given at 
night, whatever else may be in use. It has even been proposed to cure the 
disease by solid opium only. I have given it as high as six grains in the 
twenty-four hours, but, although it gave much relief, I have not seen it en- 
tirely successful. It has been proposed to substitute other narcotics, as hy- 
oscyamus and stramonium, for opium, but they are less efficacious ; though 
when the constipating effects of opium embarrass the treatment, they may 
be substituted for it. Flowers of sulphur, in small drops with laudanum, 
at night, to restrain its action on the bowels, and determine it to the skin, 
has sometimes succeeded. Relief, and sometimes a perfect cure, has also 
come from the internal use of the salino-sulphurous waters, so common in 
the Interior Valley. When their action on the bowels is restrained by 



780 THE PRINCIPAL DISEASES OF THE 

opium, they increase the secretion from the kidneys or skin. Their effects 
on the latter may be promoted by a warm bath of the same water. 

In descending to cases which lie at the bottom of the scale of febrile and 
phlogistic excitement, we come to the employment of a great variety of 
stimulating agents, not a few of which have either originated with the people, 
or been adopted from the profession and popularized. Their number proves 
their fallibility; yet there is testimony in favor of the whole, and it must 
be admitted that each has succeeded, while all have frequently failed. They 
are all stimulants, and alcohol enters into the composition of the greater 
number. Of the whole, as far as I have tried them, I prefer the ammoniated 
tincture of guaiacum, thirty drops three times a day, with an opiate and 
some diaphoretic infusion at night. And this preparation is, I think, espe- 
cially adapted to cases of lumbago and sciatica. Three of our native plants 
have acquired and maintain a popular reputation in this disease. They are 
Xanthoxylom fraxineum, prickly-ash or toothache tree ; Cimicifuga race- 
mosa, squaw-root or black-snake root; and Phytolacca decandra, or poke- 
root. Of the whole, the first is most acrid and stimulating, and therefore 
best adapted to low grades of excitement. The others act more on the secre- 
tions. They are generally given in spiritous tincture, whereby their ex- 
citing properties are increased. In different cases they are all worthy of 
being tried, but it is unnecessary to go into details on their preparation and 
doses. 

It would be a waste of time to enumerate all the topical applications which 
have been made in chronic rheumatism. Blisters often do good, and when 
the disease becomes fixed in the knee-joint, producing serous distension of 
the capsular ligament and bursa, perpetual blistering is one of our best reme- 
dies. The ointments of aconitina and veratria, I have never used. They 
appear to act powerfully on the nervous system of the part to which they 
are applied, and are best in neuralgic cases. Frictions, with animal oils 
saturated with camphor, sometimes give great relief. Hot water dressings, 
the steam being confined with India-rubber cloth, has done good. A current 
of steam, impregnated with the volatile oil of the aromatic plants, has also 
been found serviceable. But the best hot-water application is that made at 
the hot springs of Wachita, in Louisiana, or those of Virginia, which have 
frequently cured the most inveterate cases, and given singular relief and 
liberty to contracted and almost immovable joints; yet I have known them 
fail. The whole profession is familiar with the recommendations so often 
made of sulphurous fumigations, yet they are not often employed, as they 
are inconvenient, and, in fact, have been overrated. In my own practice, 
they have not proved specially beneficial. 

Percussion of the muscles of the affected limb, with the application of 
roller bandages, dipped in a saturated solution of common salt, is often 
serviceable. As a further means of re-exciting healthy muscular action and 
restoring the suspended synovial secretions, walking, and such occupations 



INTERIOR VALLEY OF NORTH AMERICA. 781 

as exercise the bands and arms, will be proper. In all cases, tbe affected 
parts and tbe general surface, should be carefully protected from cold. 

Many of the subjects of chronic rheumatism are great eaters. In one 
case, unable to control the indulgence of appetite, I attempted to moderate 
it by the administration of large doses of tartar emetic with opium, but did 
not succeed. I have no doubt that in many instances the disease is pro- 
longed, and even rendered ultimately fatal, by this excess. 

Ylil. Retrospection. — I regret that, in writing, both for and from in- 
formation furnished by the physicians of our Interior Valley, I have not 
been able to present more that is new and reliable on the treatment of rheu- 
matism. It may, I think, be seriously doubted whether within the present 
century, any important advance has been made, either in Europe or America, 
in the pathology and cure of this common, and often obstinate malady. As 
to the former, it is substantially the same with that of Sydenham, a.d. 
1675, an inflammatory diathesis and a peccant matter in the blood, both 
taking the direction of the larger joints, and the latter requiring expulsion 
from the system. A fuller acquaintance with the signs, frequency, lesions, 
and sequelae of rheumatism of the heart, and a better knowledge of the pec- 
cant materials of the blood, the qualities of the urine, and the chemical com- 
position of the tophaceous deposits of the joints, constitute the achievements 
of the last half century, or even a much longer period. 

As to remedies, it requires but a most limited retrospective research to 
learn that, with the exception of the newly discovered preparations of iodine 
and the vegetable alkalies, there is not one to which, at this time, we attach 
importance, that was not proposed fifty, a hundred, or a hundred and fifty 
years ago. Thus, Sydenham, who employed bloodletting, distinctly recog- 
nized that it may be carried too far, and that it must often be discontinued 
long before the disease is removed. After bleeding, he employed purga- 
tives, and gave opium at night to " check the tumultuary motion of the 
blood," and we now do the same thing. Tartar emetic, and tartar, calomel 
and opium combined, recommended sixty or eighty years ago, are now 
among our standard remedies. 

In the first half of the last century, colchicum, as appears from Quincy's 
Dispensatory, was a recognized remedy in gout and arthritic complaints, 
having the power of preventing the " lodgment of gritty matters in the 
joints/' and dignified with the title, anima orticulorum. The therapeutic 
transition from gout to rheumatism was almost inevitable, and before the 
end of that century, colchicum was employed in the latter disease. 

More than a hundred years ago, bark was recommended by Swan, and 
afterwards by Fothergill, in this disease ; and nearly seventy years since its 
intermittent type in certain cases was described by Trotter. 

Guaiac has been in use quite as long, for even Buchan, ninety years ago, 
directed a drachm of this medicine mixed with a drachm of cream of tartar 



782 THE PRINCIPAL DISEASES OF THE 

to be given at bedtime ; an excellent prescription. He, moreover, advised 
the volatile tincture. 

Nitre in large doses, which has lately occupied the attention of many 
distinguished physicians in Paris and London, is an old remedy in rheuma- 
tism. In the twelfth edition of Quincy's Dispensatory, 1739, it is declared 
to be a most potent remedy in every kind of inflammatory disease, which 
might be given in the quantity of "half an ounce several times a day, and 
in a few instances even more/' without ever disagreeing with the stomach 
in these doses, if " sufficiently diluted with water." Rheumatism is not 
specified among the phlegmasia in which it was employed, but Hillary, 
only twenty years afterwards, pronounced it of " great service'Vin that dis- 
ease, and Wallis, thirty years subsequently, declared it an " excellent 
remedy," proposing to begin the treatment with it, even in " people of 
athletic habits." 

The vegetable acids and the acidulous salts which are mingled with them 
in different fruits, are the latest therapeutic discoveries to which our atten- 
tion has been directed in this disease. Yet Sydenham repeatedly ordered 
syrup of lemons ; Arbuthnot, more than a century ago, recommended cream 
of tartar, which Dr. Byrd believes just as good as citric acid and lemon 
juice; and Dr. Buchan nearly as far back, joined in the recommendation, 
and also advised the acid of currants and gooseberries, known to be the 
citric, tartaric, and malic. As to mineral waters, baths, fumigations, and 
an endless catalogue of stimulants and irritants, internal and external, the 
catalogue of the present is essentially that of the last century ; or, if some 
new agents have superseded older ones, the results of their application have 
shown that love of novelty or notoriety has chiefly contributed to the 
change. 

In medicine, as in every imperfect and experimental science, it is useful 
now and then to compare its present condition with the past ; for we may 
be moving in a circle, while our course seems straight forward, and reviv- 
ing old observations instead of making new ones. When such is the fact, 
we ought to know it; and the retrospection which reveals it may sometimes 
suggest new and more successful methods of inquiry. 



SECTION II. 

OPHTHALMITIS. 

I. The various tissues of the eye are subject to inflammation, either 
separately or in combination. From external violence, as the explosion of 
a fire-cracker, the conjunctiva, cornea, iris, and sclerotica, are sometimes 
involved in the same inflammation, under which the textures are rapidly 
disorganized, pus is secreted, and the eye, said by the people to burst, pours 
out its aqueous humor, crystalline lens, and a portion of the vitreous humor, 



INTERIOR VALLEY OF NORTH AMERICA. 783 

mingled with the sero-purulent secretion. This, which is a true ophthal- 
mitis, is not very common, and as far as I have seen, requires external 
violence for its production. In early times, when over the middle portions 
of our Interior Valley, the quarrels of men (now resulting in the use of 
the bowie knife and revolving pistol), were settled by the natural method 
of combat with unarmed hands, gouging was a general custom, and where 
life is taken now, an eye was lost then. Thus it is, that the manners of a 
people modify their diseases, which are never precisely the same in two 
successive ages. The favorite popular remedy for an eye which had suffered 
the compound violence of concussion, compression, and laceration, was the 
immediate application of fresh meat, as a piece of recently killed beef, but 
the common resource was a chicken " cut in two/' and applied while the 
flesh was still quivering. As no inflammation had yet been set up, its 
effects, which I am not disposed to think highly of, were preventive. When 
a severe inflammation was not thus warded off, the eye was frequently de- 
stroyed. Inflammation once established in cases of this kind, the most 
active antiphlogistic treatment was required. But we must direct our atten- 
tion to the inflammations limited to or at least commencing in single tissues 
of that multiplex organ, beginning, for the sake of a natural transition from 
the subject of the last section, with that seated in the sclerotic coat. 

II. Sclerotitis. — Primary sclerotic inflammation in this country is 
comparatively rare, and very generally of rheumatic origin. It is both 
acute and chronic, but a large proportion of all the cases I have seen were 
of the latter class. The characteristic symptoms are pain and aching, not 
external heat and smarting, referred to the globe and orbit of the eye, often 
compared to that of rheumatism in the joints, and like it generally worse 
at night and in foul weather. As long as the inflammation does not extend 
to the iris or retina, the intolerance of light, though considerable, is much 
less than in those complications or in strumous ophthalmia. The external 
discharge is lachrymal rather than mucous. The vessels of the conjunctiva 
are but little engorged, and therefore the vascular condition of the sclerotic 
coat can be observed. It is one of congestion, but in a circle near the cornea 
the white is generally undimmed. Exterior to this, vessels display a light 
red and bluish tint. As in all cases of intolerance of light, the pupil con- 
tracts, which might suggest iritis when it does not really exist ; yet as it 
often supervenes, the physician should be on his guard that he does not 
permit the contraction to become permanent. As a further diagnostic aid 
we generally find the patient to have immediately or remotely suffered from 
articular rheumatism, or a previous attack of sclerotitis. In some cases it 
extends to the cornea, which it renders turbid. When this affection goes 
on to the destruction of the vision, it is not always by obliterating the pupil, 
butoftenerby extending to the choroid and retina, destroying the sensibility 
of the latter, and dissolving the vitreous humor. In old cases of this kind, 
the vessels of the sclerotica suffer varicose enlargement, the membrane 



784 THE PRINCIPAL DISEASES OF THE 

assumes a leaden or livid hue, and the easily compressed eyeball becomes 
more or less tuberous and amorphous in front. It is unnecessary to say 
that such cases of amaurosis as they are sometimes called are altogether in- 
curable. 

On account of its diagnosis, I have preferred to place this affection among 
the ophthalmitis ; but in reference to its treatment it is properly classed 
with rheumatism. The duty of the physician is to detect its rheumatic cha- 
racter, and having done so, to treat it as he would that disease — whether 
acute or chronic — when seated in any other part. Of course collyria, the 
routine resort in u sore eyes," will afford little aid in this form of disease. 

III. Iritis. — This affection, often syphilitic or traumatic, as when fol- 
lowing on operations for cataract, and often leading to operations for closed 
pupil, belongs rather to surgical than to medical practice. I shall therefore 
not dwell upon it very long. Its causes, partly suggested by what has just 
been said, are still further a rheumatic, and in some countries a gouty dia- 
thesis, external violence, and punctured wounds. In these various cases the 
inflammation may commence in that organ, but it may also be secondary, 
or an extension from the sclerotica, or from the cornea, connected with the 
iris by the membrane of the aqueous humor; finally, conjunctivitis may dip 
through the subjacent tissues and involve the iris. Scrofulous iritis is I 
think a rare disease, and I do not recollect, in many cases of that form of 
ophthalmia, to have seen any serious lesion of the iris. 

Uncomplicated iritis may be distinguished from conjunctivitis, corneitis, 
and sclerotitis, by the comparative absence of hyperasinia in the tunics 
which are the respective seats of those affections, and from retinitis by greater 
tolerance of light. The pain is often very acute, and extends to the orbit 
and even whole head, but chronic cases may form a great exception. The 
positive diagnosis is chiefly derived from the appearance and movements of 
the iris itself, when the cornea is clear and permits the affected part to be 
seen. At a comparatively early period its movements become sluggish under 
varying quantities of light, with a prevailing tendency to contraction of 
the pupil. It soon begins to display a wrinkled appearance ; and at the 
same time undergoes a change of color. This, in black or hazel eyes, is a 
reddish or blood hue, but in eyes of a lighter hue, it is some shade of green 
or yellow, a tint which has long been regarded as diagnostic of this affec- 
tion. The organ seems to thicken from congestion, and very soon its pupil- 
lary margin shows deposits of coagulable lymph, which are sometimes made 
on its anterior surface, and sometimes plug up the already contracted pupil. 
When the inflammation is intense it extends to the sclerotica, cornea, and 
even the conjunctiva. A fibrinous exudation is the common product, but 
suppuration sometimes occurs, and a small abscess discharges its contents 
into the anterior chamber, and contributes with the sero-lymphatic secretion 
of the serous membrane of that cavity to the turbidity of the aqueous 
humor. The pupil does not always close, for the iris may become fixed 



INTERIOR VALLEY OF NORTH AMERICA. 785 

before the contraction is completed. It generally then loses its circular 
figure. In some cases the pupillary margin of the iris is agglutinated to the 
lens; but in others after the, pupil has become closed by contraction or 
with effused coagulated lymph, it bulges forward towards the cornea from 
exudations behind. Now and then extravasations of blood from the distended 
•vessels take place into the anterior chamber. When the inflammation is 
mild, extensive disorganization may occur, with but little constitutional dis- 
turbance; but the acute forms are often accompanied with severe inflamma- 
tory fever ; and the forfeit of delayed or feeble treatment, may be irreme- 
diable blindness, or submission to an operation for artificial pupil, often 
difficult or unavailing, from the extension of the inflammation to the cornea 
and its consequent opacity. As the inflammation may extend to the retina, 
vision may be lost in another way by the disorganization and insensibility 
of that organ. 

Simple acute iritis is a serious inflammation, demanding an active anti- 
phlogistic treatment. But the effect of bloodletting is not always propor- 
tionate to the quantity drawn, for the eye is, anatomically, so loosely con- 
nected with the organism, that it does not readily feel the loss of blood by 
venesection, but at the same time is acted upon perhaps the more favorably 
by cupping and leeching. General bloodletting, however, when it may not 
immediately diminish the hyperemia of the iris, prepares the way for and 
increases the efficacy of other measures. Among these at the beginning 
copious purging, as making revulsion from the head, is indispensable, and 
yet mere depletion of the bloodvessels and the bowels should not be our 
sole, nor in many cases, our greatest reliance. An antiphlogistic alterant 
is necessary, and no other can be compared with calomel. Its power over 
acute hepatitis is not greater than over iritis, and it should be administered 
in dangerous cases to the extent of two or three scruples in the twenty-four 
hours, till the inflammation yield or a salivation is induced. If it should 
excite the bowels beyond the effect of an aperient, opium should be com- 
bined with it, the exhibition of which will be safe, and its effects salutary 
as an antiphlogistic in proportion to the previous bleeding, and the degree 
of constitutional irritability that may have been awakened. In cases of a 
less acute character, local bleeding may suffice, and the calomel should be 
administered in smaller doses, as it must be continued for a much longer 
time. When the constitution was previously impaired opium is a valuable 
adjuvant. An acute inflammation may seem to be cured, and yet linger in 
the affected tissue till irreparable mischief is done, or it may from the be- 
ginning be so mild, as to excite no alarm till slowly induced lesions make 
their appearance; in all such cases a mild mercurial course is the chief re- 
liance, though in such grades a blister to the temple, or over the entire orbit 
of the eye, the lids being closed, is an important auxiliary. The inflamma- 
tion being finally arrested, its consequences when such exist are to be re- 
moved. These consist in the depositions of lymph as yet unorganized, and 

vol. ii. 50 



786 THE PRINCIPAL DISEASES OF THE 

the contraction of the pupil. To promote the absorption of the former the con- 
tinued exhibition of calomel or blue pill, and when the powers of the system 
are greatly weakened, the simultaneous administration of bark and opium, 
are the internal remedies, the bowels at the same time being kept regular. 
But a watery solution of opium used as a collyrium, and repeated small blis- 
ters around the orbit, contribute greatly to promote the absorption of the 
exudations. The other object is to be fulfilled by the application of the 
extract or juice of stramonium, or the extract of belladonna, diluted with 
water, to the conjunctiva, and in obstinate and increasing contractions, by 
the internal administration of the former. We need not and should not 
defer the external application till the inflammation is reduced, but endeavor 
in its midst to keep the pupil dilated, that if the physiological action of the 
iris should be annihilated, an aperture for the admission of light might re- 
main and render an artificial opening unnecessary. Of course whenever the 
inflammation is violent, exclusion of strong light, all active use of the eye, 
and rigid abstinence are necessary. 

When iritis is of syphilitic or gonorrheal origin, bloodletting is of less 
value than in the simple form of the disease, and calomel more important. 

Rheumatic iritis requires the treatment appropriate to that peculiar dis- 
ease. It is, perhaps, always associated with sclerotitis. Mercurials are of 
less value than in the other forms. Colchicum is an important remedy, and 
Dr. Hays, who has had an ample experience, is accustomed to give it in the 
form of Scudamore's mixture (already quoted) combined with spirit of tur- 
pentine. There is less danger of lesions of the iris in this variety than in 
simple iritis. 

Strumous iritis, generally connected with the same kind of specific inflam- 
mation in the cornea or conjunctiva, will be noticed under the latter head. 



INTERIOR VALLEY OF NORTH AMERICA. 787 



CHAPTER XL 

PHLEGMASIA OF THE RESPIRATORY ORGANS.— ETIOLOGY. 

INTRODUCTION. 

The phlegmasia of the respiratory organs, including the tubercular with 
the simple, are, beyond all doubt, more common and fatal than those of any 
other group of organs, indeed of all others taken together. I may even go 
further, and express the belief that, should accurate statistical tables be ever 
formed for our whole Valley, they will show that these respiratory affections 
afford a greater outlet of human life than any other natural family of our dis- 
eases, not even excepting our much-dreaded periodical or autumnal fevers. 
If this be so, they well deserve to fix our attention. 

Still pursuing the method of analysis, I shall first present what in a 
manner is common to the whole. This, however, can be extended no 
further than their causes, after which the group itself must be analyzed by 
taking up the different species in succession. Having discussed the modus 
operandi of causes of inflammation, and a phlogistic diathesis, our task now 
and hereafter will be limited to an historical view of the relation between 
different phlegmasiae and the agents or influences which seem to produce 
them. 



SECTION I. 

CLIMATIC, GEOGRAPHICAL, AND HYDROGRAPHICAL CAUSES. 

I. The connection between climate and pulmonary disease* is an esta- 
blished fact. Other diseases have their climatic relations ; but, in general, 
they are indirect, or mixed up with various causes. Thus, without water 
and dead organic matter, warm climates do not produce yellow and periodical 
fevers; without filth and poverty and confined lodgings, the colder do not 
generate continued fevers. In the production of pulmonary phlegmasiae, 
climate is no longer an agent quickening others into life, or a required con- 

* I use, for convenience, the word pulmonary, as synonymous with respiratory — that is, as including 
the trachea, larynx, and nares — indeed, the whole apparatus of respiration. 



788 THE PRINCIPAL DISEASES OF THE 

dition of their action on the body. Geographical and hydrographical influ- 
ences must be admitted; but they act only by modifying the meteorological, 
which latter, ceasing to play subordinate parts, immediately and alone light 
up these inflammations. 

Every settled portion of our Interior Valley is infested with these mala- 
dies ; but as we cannot yet assign their comparative prevalence, we do not 
know what varieties of climate are most productive of them. And here is 
a case in which medical statistics might throw much light on the philosophy 
of etiology.* 

II. The chief statistics which we at this time possess, are those afforded 
by the Army Returns of the United States and Canada. I shall first present 
our own. They are drawn from twenty-six military posts, scattered over 
the Valley, from the latitude of 46° down to 24°, but cannot be regarded 
as an exact exponent of the prevalence of the various forms of pulmonary 
inflammation among the people at large. For they exclude females, chil- 
dren, and aged persons; they do not embrace cities; they do not compre- 
hend any persons who at the time of enlistment appeared strongly predis- 
posed to phthisis ; and they relate to men who on the whole were greatly 
exposed. Thus they belong strictly to a particular class ; but as this class 
was the same at all the posts, and the occupations, diet, dress, and exposures 
the same, these statistics very fully set forth the relative influence of dif- 
ferent climates and localities upon one order of men. Still even to this 
there is one exception ; the returns of some posts are much more copious 
than others; either from more numerous garrisons, or from the returns 
runniug through a longer period of time. If all the posts had been of the 
same strength, and the number of years had been equal, a statement of the 
results would be an easy task; and the actual numbers might be given. In 
the absence of such equality, a different course must be pursued, and I have 
therefore thrown the whole into decimals, showing what the actual returns 
would have been, if the number of men at each post had been 1000. Thus, 
in the tables which follow, the number affected with different forms of pul- 
monary disease is not that which is given in the returns, but the number 
that would have been given, if the mean strength of each garrison had been 
1000. I have also modified to some extent the classification of the posts, as 
that given in the Army Register embraces several which lie beyond our 
limits. 

* The author has learned from various sources that the article Climate (Book I. Part II.) is slurred 
over by many physicians of the region to which it relates, yet they continue to write on the weather, 
and diseases of their localities! Perhaps they regard weather as distinct from meteorological condi- 
tions. He regrets that in catering he should have been obliged to provide food too hard to be digested. 
Yet the case is not peculiar. Anatomy has been found indigestible by many successful students of 
physiology; others have become good pathologists without studying morbid anatomy; not a few have 
gotten on well with pharmacy and toxicology, without troubling themselves with the definite propor- 
tions of chemistry ; and why may not some understand the weather, and its etiological bearings, without 
studying the science of meteorology. 



INTERIOR VALLEY OF NORTH AMERICA. 789 

III. The groups which I have formed are the five following : 1st. Upper 
Lake posts ; 2d. Lower Lake posts ; 3d. Northern Inland posts ; 4th. 
Southern Inland posts ; 5th. Gulf posts. By a reference to the article on 
climate, it will be seen that these groups represent real climatic and geogra- 
phical divisions. Table I., on next page, will be found, by those who study it 
carefully, to embrace a great number and variety of results, expressive of the 
relative prevalence of different forms of pulmonary inflammation in the dif- 
ferent seasons of the year, and in different localities, through a period of 10 
years, reduced to a mean year. The decimals in the table might have been 
carried to two or three figures, but it seemed better as far as possible to 
avoid fractions. 

It may be advantageous to readers not conversant with statistical tables, 
to illustrate the use of this by an example. Let us then select two inland 
posts far distant from each other, and compare them, according to the num- 
bers of the table. If 1000 soldiers should pass a year at Fort Snelling, 
44° 53' lat. N., there would be 643-3 attacks of pulmonary disease; viz. : in 
the first quarter of the calendar year 135-7 cases of catarrh, influenza, and 
bronchitis; in the second, 207-6; in the third, 120-8; in the fourth, 
136 = 600. Of pneumonia and pleurisy there would be in the several 
quarters, 12-2; 25 3 ; 11-2; 12-0 = 40-7. Of phthisis there would be in 
the year 2-6, making an annual aggregate of 643-3. When we return to the 
line for Fort King, 28° 58' lat. X., we see the numbers which correspond to 
these, which need not be written out like them, but may be placed with 
them for comparison as follows : — 



Fort SnelliDg, 
Fort King, 



Catarrh, Influenza, 
and Bronchitis. 


Pneumonia and 
Pleurisy. 


Phthisis. 


Total 
for the year. 


600 


40-7 


2-6 


643 3 


101-2 


30-7 


9-8 


141-7 



Thus it is revealed to us that the rigorous climate of Fort Snelling is far 
more productive of mucous inflammation than the milder climate of Fort 
King — that in pneumonia and pleurisy they differ much less, and that in 
phthisis the numbers are reversed, that disease prevailing more at the south- 
ern than the northern post. By thus comparing places similarly situated as 
to land and water, but in different latitudes, or differently situated in these 
respects but in the same latitudes, we augment our knowledge of the rela- 
tions between various portions of our Valley and the pulmonary phlegmasia. 
But large portions of the Valley may be compared with each other, by bring- 
ing together the averages in the left horizontal line of each section of the 
table : which also presents dat£ for ascertaining the relative influence of the 
seasons. 



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Fort Jessup, . . . . 



792 



THE PRINCIPAL DISEASES OF THE 



Many subordinate tables might be constructed out of the numbers here 
given. The following are the most important : — 

TABLE II. 

OF THE RELATIVE PREVALENCE OF THE DIFFERENT FORMS OF PUL- 
MONARY INFLAMMATION AT THE GROUPS OF POSTS. 







a 






o £\2 


**1 


Groups of Posts. 


.a S 
o a 


a 
o 
S 

J3 
o 

a 


.2 

3 
o 


m 


- a «« 
a c a 
SB g 


Catarrh 
compared 
Pneumoni 
Pleurisy, 
Phthisis. 


Twenty-six Posts — Average, . . 


343 


21-8 


37 2 


7-2 


409 


As 5-2 to 1 


Six Upper Lake Posts, .... 


263-4 


12 2 


27-3 


7-1 


310 


As 5 -7 to 1 


Two Lower Lake Posts, . . . 


496-1 


33 3 


22-3 


50 


556-8 


As 8 1 to 1 


Four Northern Inland Posts, . . 


479 9 


144 


38-3 


6-2 


538 8 


As 8-1 to 1 


Six Southern Inland Posts, . . 


252 7 


31 2 


61-0 


8-8 


333 7 


As 31 to 1 


Eight Gulf Posts, 


223 


17-7 


37 1 


90 


286-7 


As 3-6 to 1 



TABLE III. 

SHOWING THE PREVALENCE IN THE DIFFERENT GROUPS OF POSTS, OF 
CATARRH, INFLUENZA, AND BRONCHITIS, IN THE DIFFERENT QUARTERS 
OF THE CALENDAR YEAR. 



Groups. 


First 
Quarter. 


Second 
Quarter. 


Third 
Quarter. 


Fourth 
Quarter. 


Aggregate. 


Lower Lake, 

Northern Inland, 

Southern Inland, 

Upper Lake, 

Gulf, 

Average, ; . . . 


162 

166-2 

102-2 

83-5 

84-9 


98-2 
124 9 
440 
55-5 
40-9 


58-8 
63-6 
381 
46-0 
370 


177-1 

125-2 

63-3 

72-4 

60-2 


496-1 
479 9 
247-6 
263-4 
223 


598 8 


363-5 


243-5 


498-2 




119-8 


72-7 


48-7 


99 6 



TABLE IV. 

SETTING FORTH THE COMPARATIVE LIABILITY OF THE DIFFERENT GROUPS 
OF POSTS TO PULMONARY INFLAMMATION, BEGINNING WITH THE MOST 
INSALUBRIOUS. 

Diseases. Posts. 

Catarrh, Influenza, and c Lower Lake; Northern Inland; Southern Inland; 
Bronchitis, . . . . I Upper Lake ; Gulf. 

( Southern Inland; Lower Lake; Gulf; Northern 
Pneumonia, \ Inland . Upper Lake. 

C Southern Inland; Northern Inland; Gulf; Upper 
Pleuris y> I Lake; Lower Lake. 

( Southern Inland; Gulf; Upper Lake; Northern 

Phthisis, j T \ a r t i 

C Inland ; Lower Lake. 

All forms of Pulmonary In- C Lower Lake ; Northern Inland ; Southern Inland ; 
flammation, . . . . ( Upper Lake ; Gulf. 



INTERIOR VALLEY OF NORTH AMERICA. 



793 



TABLE V. 

SHOWING THE RELATION OF DISEASES OF THE RESPIRATORY ORGANS TO 
ALL OTHER DISEASES; EXCLUDING ACCIDENTS AND VENEREAL AFFEC- 



TIONS. 



FOUR NORTHERN INLAND POSTS. 



Fort Snelling, as 1 to . . 


. 2-0 


Fort Crawford, as 1 to 


. 30 


Fort Armstrong, as 1 to 


. . 3-8 


Fort Leavenworth, as 1 to 


. 48 




3-4 mean 


SIX UPPER LAKE 


POSTS. 


Fort Brady, as 1 to 


. 2-5 


Fort Mackinac, as 1 to 


. 3-7 


Fort Howard, as 1 to . 


. . 4-2 


Fort Winnebago, as 1 to 


. . 1-7 


Fort Gratiot, as 1 to . 


. 43 


Fort Dearborn, as 1 to 


. 80 


, 


4-4 mean 



TWO LOWER LAKE POSTS. 

Madison Barracks, as 1 to . 3-4 
Fort Niagara, as 1 to . . . 4-0 



SIX SOUTHERN INLAND POSTS. 

6-6 
8-2 
8-4 

12-2 
4-0 

12-4 



Jefferson Barracks, as 1 to 
Fort Gibson, as 1 to . . 
Fort Smith, as 1 to . . 
Fort Towson, as 1 to 
Fort Jessup, as 1 to . . 
Fort Mitchell, as 1 to 



EIGHT GULF POSTS. 

Baton Rouge, as 1 to . . 13 
Fort Pike, as 1 to ... . 5 

Fort Wood, as 1 to . . . 5- 
New Orleans Barracks, as 1 to 6 

Fort Jackson, as 1 to . . 13 

Fort King, as 1 to ... 13 

Fort Brooke, as 1 to . . . 7- 

Fort Key West, as 1 to . . 13- 



9-9 mean. 



Si mean. 
Mean of twenty-six posts as 1 to 6-992, say 700. 

Let us turn our attention to the conclusions which may be drawn from 
the data furnished by these tables, considering the groups of posts seriatim. 

I. Lower Lake Posts. — Fort Niagara is situated at the entrance of the 
river bearing that name, into Lake Ontario, near its western extremity j and 
Madison Barracks, at Sackett's Harbor, is on the eastern extremity of the 
Lake. Of all the "great lakes," this is the smallest and most detached 
from the group. To the southeast, at no great distance, lie the mountains 
of New York and Vermont; to the north' of both posts, and to the north 
and northwest of the barracks, there is land. Thus, although literally lake 
posts, the lacustrine influences are very much reduced ; which approximates 
them in condition to the inland posts of corresponding latitudes, which they 
even exceed in the high ratio of pulmonary diseases. But there is another 
cause for the same result. Ontario is the source of the river St. Lawrence, 
which reaches the Atlantic Ocean by a northeast course, and hence the posts 
upon its shores are peculiarly exposed to the northeast winds which traverse 
the continent from the Gulf of St. Lawrence to the Gulf of Mexico. By 
this great atmospheric current, the chill and damp air of the ocean off New- 
foundland, in the latitude of 50°, is wafted over these posts; and to it we 
may ascribe in part the great prevalence of pulmonary inflammation. The ab- 



794 THE PRINCIPAL DISEASES OF THE 

sence of phthisis at Madison Barracks may be regarded as accidental, inas- 
much as Fort Niagara presents a full proportion. In pneumonia, these posts 
are above, but in pleurisy below all the other groups. It is proper, however, to 
state that the returns of these garrisons only extend through about half the 
period of those from other posts, and do not therefore approximate so closely 
to the truth as those which are made through a more protracted time. 

II. Upper Lake Posts. — The mean latitude of this group is about the 
same with that of the preceding. They are all so situated in reference to 
the four great lakes, Superior, Michigan, Huron, and Erie, as to feel the 
influence of those broad and deep waters. Winnebago presents an apparent 
exception, and is classed with the inland posts in the army statistics; but 
topographically it might, with greater propriety, be grouped with the lacus- 
trine — a decision which is fully sustained by its closer resemblance to them 
than the neighboring inland posts, in the ratio of its pulmonary diseases. 
Of this group, Fort Gratiot, at the southern extremity of Lake Huron, lies 
most in the highway of the northeast wind already mentioned, and presents 
the highest ratio of pulmonary diseases. Fort Dearborn lies furthest 
south, and, at the same time, is less exposed to these winds, which more- 
over reach it after traversing Lake Ontario and Lake Michigan : its ratio of 
pulmonary diseases is the lowest. The mean of the whole group is less 
than that of all the posts, and much less than that of the posts on Lake On- 
tario, or of the four inland posts nearly in the same latitude to the west. 
Thus, as far as the army returns can be relied upon, these large sheets of 
water seem to diminish the prevalence of every form of pulmonary inflam- 
mation, for the ratio of the whole are below the general average. The ratio 
of pneumonia is even lower than that of any other group of posts, and that 
of pleurisy lower than any other but one. The ratio of pulmonary diseases 
to all others, exclusive of accidents and venereal affections, is as one to four : 
the corresponding ratio for the preceding group of posts, is as 1 to 3 7; but 
this does not prove the shores of Lake Ontario to be healthier than those of 
the upper lakes, but the reverse, since, as we have already seen, nearly twice 
as many cases of pulmonary disease occur in a given number of persons in 
the former as in the latter. The distribution of pulmonary diseases through 
the four quarters of the year, is such as might be expected at posts sur- 
rounded by lakes which are warmer in winter and cooler in summer than 
land. Thus, if we take the first and third quarters as presenting the maxi- 
mum and minimum, we find that in the upper lake group we have 83-5 for 
the former, and 46- for the latter, while the corresponding number for the 
lower lake, are 162 and 58-8, and for all the groups 120 and 49, rejecting 
fractions. 

III. Northern Inland Group. — The four posts of this group lie be- 
tween the 45th and 39th degrees of latitude, west of Ontario, Erie, Huron, 
and Michigan, and south and southwest of Lake Superior. They are con- 
sequently but seldom visited by winds which have passed over those lakes, 



INTERIOR VALLEY OF NORTH AMERICA. 795 

but are greatly exposed to those from the west and northwest, as they de- 
scend from the Rocky Mountains over the arid inclined plain which stretches 
from those mountains to the trough of the Mississippi. The ratios of pul- 
monary disease at Fort Crawford and Fort Snelling, the two northern of 
these posts, are greater than any others except Madison Barracks, nearly in 
the same latitude. The ratios of Fort Armstrong and Fort Leavenworth, 
lying further south, are only two-thirds as great. The mean of the whole, 
a little less than that of the lower Lake or Ontario group, but almost twice 
as high as that of the Upper Lake group ; a difference which connects itself 
with catarrh and pleurisy ; the former rising nearly 100 per cent., and the 
latter 33 per cent, above the lake group, while in pneumonia and phthisis, 
the two groups are nearly equal. The distribution through the quarters of 
the year of the pulmonary diseases of this group conforms to the law of 
extreme variation of the temperature. Thus the number of cases of catarrh 
in the first quarter is twice as great as in the upper lake group, in the 
second more than twice, but in the third only '25 per cent, greater, while in 
the fourth it is greatest of all, showing the influence of the lakes, warmed 
by the summer, in moderating the violence of autumn. Compared with all 
the posts, this group is 71 per cent, above the general average in catarrh; 
33 per cent, below it in pneumonia, and nearly equal in pleurisy and 
phthisis. In the aggregate it is above all the groups except the Ontario or 
lower lake, which it nearly equals. The number of pulmonary inflamma- 
tions in this group compared with all other diseases, is as 1 to 34, while 
the ratio of all the posts is 1 to 7, or less than half as great; that of the 
adjoining upper lake group as 1 to 4-0, or seventeen per cent, less; that of 
the lower lake as 1 to 3-7, or nearly 9 per cent. less. Thus the proportion 
of pulmonary to all other diseases in the northern inland, is greater than 
in any other group. 

IV. Southern Inland Group. — This group, comprising six posts, lies, 
with the exception of Fort Mitchell, which is situated on the eastern edge 
of Alabama, directly south of the last, and has to its west the inclined plain 
which ascends to the Kocky Mountains. The mean aggregate of pulmonary 
disease is 333-7, that of the group above being 538-8. By examining the 
general table, it will be seen that the posts of this group present a regular 
decrease from Jefferson Barracks, the furthest north, down to Fort Jessup, 
the most southern, which last, however, constitutes a striking exception on 
the scale of diminution, as the number of its cases is 517, being more even 
than that of Jefferson Barracks. Xo explanation of this anomaly is pre- 
sented in the Army Statistics by the surgeons of the post, or by Dr. Forrey 
in his comments on them. TTe only know that the Fort is situated on an 
elevated and arid pine plateau, between Red River and the Sabine, at the 
distance of 100 miles in a direct line from the Gulf of Mexico. Let us for 
the present exclude this post, and proceed to inquire into the ratio of de- 
crease in bronchial inflammations, as we descend through the whole range 



i\)b THE PRINCIPAL DISEASES OF THE 

of inland posts from Snelling and Crawford in the mean latitude of 44° down 
to the mean latitude of Towson and Mitchell, which may be taken at 32°. 
Between these parallels there are five other posts. Now the mean ratio of 
cases at the two upper posts is 600, that of the two lower nearly 120 — dif- 
ference 480. If we divide this by 12, the difference in latitude, it gives us 
a quotient of 40 ; which is the decrease for each degree of latitude in ad- 
vancing from north to south. We are not at liberty to exclude Fort Jes- 
sup, but join it with Towson and Mitchell : we have an average of 222 for 
the catarrhal affections of the southern part of this group; which reduces 
the ratio of diminution through the 12° of latitude from 40 to 31-5 for 
every degree. The decrease is not, however, equable j still it is sufficient to 
show, that as we traverse the centre of the continent from North to South, 
catarrh and other bronchial affections diminish. 

The other pulmonary affections do not conform to this but to an opposite 
law. Thus in the northern inland group the catarrhal cases are to all others 
as 480 to 59 ; while in the southern the ratio is 253 to 101. In fact, while 
catarrh diminishes as we go south, pneumonia, pleurisy, and phthisis 
increases. 

In the southern inland group, the proportion of cases to the number of 
men, is as 1 to 13-2; in the northern, as 1 to 7 3. In the former, the 
number of cases of pulmonary disease compared with all others is as 1 to 
8-6; in the latter, as 1 to 3 4. Thus in the northern group, pulmonary 
diseases bear a higher ratio both to the number of men and to other diseases 
than in the southern group. 

V. Group of Gulf Posts. — These extend from Baton Bouge, in lat. 
30° 36', to Key West, in lat. 24° 33'— that is, through 6°. Baton Bouge 
and Fort King are situated about 50 miles on a straight line from the Gulf, 
the rest are on its margins. These posts present much irregularity in the 
numbers which express the relative prevalence of the different forms of pul- 
monary disease, but no law of increase or decrease through the 6° of lati- 
tude. Thus the two extreme posts, Baton Bouge and Key West, present 
the same amount of catarrh ; Fort Brooke gives more than Fort King or 
Fort Jackson, although further south than they, and Forts Pike and Wood 
differ widely in their numbers, notwithstanding they lie in the same locality. 
Similar remarks would be equally true of the other forms of pulmonary 
disease. But let us compare this group with the last which rests upon it to 
the north. The difference between them is, catarrhal cases, 19-7, pneumo- 
nia, 13-5, pleuritic, 242, phthisical, nothing. These differences give 13-76 
and 65 per cent. Hence it appears, that around the Gulf the cases of catarrh 
approach much nearer to the cases in the adjoining group of posts to the 
north, than the cases of pneumonia and pleurisy. In other words, the in- 
fluence of the Gulf coasts, in reducing the ratio of pneumonia and pleurisy, 
is greater than its influence in abating catarrh. The last disease is, in fact, 
more prevalent in this group, compared with the southern inland group, 



INTERIOR VALLEY OF NORTH AMERICA. 797 

than it is in that group compared with the northern. This is demonstrable. 
For example, between the centres of the two inland groups there are 9° of 
latitude, and the difference in the ratio of catarrhal cases is 228 ; from the 
centre of the southern inland group to that of the Gulf, there are 6° of lati- 
tude, which, at an unaltered ratio, would give 148 as the difference of cases, 
whereas, it is only 30. Now, why is it, that as we reach and continue 
south on the shores of the Gulf, the ratio of decrease in catarrh is retarded ? 
There is no obvious cause but the Gulf itself; in what manner, however, 
does it favor the production of catarrh, or counteract the influence of in- 
creased heat in diminishing that disease ? A mixture or alternation of land 
and sea air may perhaps be the cause. 

That it is not referable to mere humidity will appear on comparing the 
Gulf posts with the upper Lake posts. Although situated 16° further 
north, in the same parallel with the northern inland group, the Lake group 
presents the low ratio of 264 for catarrh and 310 for all pulmonary dis- 
eases, while the Gulf posts give us 223 and 288. Thus 1000 men on the 
shores of the northern Lakes will afford but 41 cases of catarrh and only 
22 cases of all kinds of pulmonary disease more than the same number on 
the shores of the Gulf. In fact, while catarrh is a little more prevalent, 
other forms of pulmonary disease are less so on the upper Lakes than on the 
Gulf, which demonstrates that the vapor of fresh water does not tend to 
produce pulmonary disease, since the difference of temperature alone ought 
to give a greater number in the North than in the South. 

In the group of Gulf posts, the proportion of pulmonary disease to all 
others, was one to ten ; in the group immediately north, as one to eight 
and six-tenths; the proportion of the same disease to the number of men 
is one to fifteen in the former and one to thirteen and two-tenths in the 
latter. 

III. Let us turn our attention to the Canadian statistics of the British 
army.* It is not practicable to incorporate these with the statistics of our 
own, because the returns of different posts are not given, nor are quarterly 
periods observed. The posts of Upper Canada West are Penetanguishire, 
on Lake Huron, Amherstberg, or Maiden, on Lake Erie, and Fort George, 
Toronto, Bytown, and Kingston, on or north of Lake Ontario. The posts 
in Lower or East Canada are Montreal, on the River St. Lawrence ; Isle 
du Noix, St. John, Chambly, and William Henry, on the Richelieu, which 
connects Lake Champlain with the St. Lawrence ; lastly Quebec, the most 
eastern and northern of the whole. 

It appears that for a period of twenty years, during which the aggregate 
force at these and all other posts in the two Canadas was 64,280, the 
number of cases of pulmonary disease was 9,061, or 140 per 1,000 mean 
strength, a prevalence far below that of any of the posts of the United 
States, even those of the South. 

* Tulloch's Reports, London, 1S39, p. 28, b. 



798 



THE PRINCIPAL DISEASES OF THE 



The following are the forms of pulmonary disease in the 9,061 cases : — 



Inflammation of the lungs, . 








. -2,774 


Spitting of blood, 








129 


Consumption, 








402 


Acute catarrh, 








. 5,135 


Chronic catarrh, 








569 


Asthma, . 








39 


Difficulty of breathing, 








11 


Pain in the chest, 








1 


Hooping cough, 








1 



Total, 



9,061 



The difference between the Canadian posts and those of the adjacent 
parts of the United States, is not to be found in phthisis, pleurisy, or pneu- 
monia, but in catarrh. For the proportion of phthisis, the same of pleu- 
risy and pneumonia nearly the same, but of catarrh much less. 

The relative prevalence of pulmonary disease in Upper and Lower Canada 
during 10 years, is presented in the following table : — 







UPPER CANADA. 


LOWER CANADA 






Per 1000 mean 


Per 1000 mean 






strength. 


strength. 


Inflammation of lungs, 


30 


1 


60 1 


Consumption, . . . 


5 


[ 80 


7 I 139 


Catarrh, ..... 


45 


J 


72 J 



From this table, it appears that the Canadian posts on the Lakes are but 
more than half as liable to pulmonary disease as those on the St. Lawrence; 
showing conclusively the influence of large bodies of water in diminishing 
the production of those diseases. According to Major Tulloch, some allow- 
ance should be made, however, for soldiers from the upper posts stopping 
at the lower, when on their way to England, to be invalided ; nevertheless, 
we are warranted in saying that the country to the east of the great lakes, 
not less than that to their west, is more subject to pulmonary diseases than 
the intervening or lacustrine region. 

The army statistics of the two nations, which we have presented, show in 
a general way the connection between climate and pulmonary disease from 
the Gulf of Mexico and the Gulf of St. Lawrence, as observed among 
soldiers ; but we must not neglect observations made in civil life, although 
they may be less exact and extensive. 

IV. Wherever I have travelled within the limits just mentioned, pul- 
monary inflammations have been enumerated both by physicians and the 
people among their prevalent diseases; some form or grade of catarrh or 
bronchitis, being always more frequent than all other affections of the re- 
spiratory organs taken together. The inhabitants of both city and country 
are liable, but whether in the same degree I am unable to state. My im- 



INTERIOR VALLEY OF NORTH AMERICA. 799 

pression is that the country population are more subject to pleurisy and pneu- 
monia than the city, while catarrh is nearly equally common among both. 

Everybody expects catarrh and otber pulmonary diseases, when a sudden 
change of weather takes place. Even a change from cold to heat sometimes 
produces catarrh ; but in most cases it is the opposite transition which 
originates the local epidemic. Now it is worthy of remark, that many sud- 
den changes occur every year, without generating much catarrh ; and also, 
that it is not uncommon to see that form of disease exceedingly prevalent 
when the changes of temperature have been very slight. Indeed, every ob- 
serving physician in our middle latitudes must have remarked, that during 
the dry and frosty weather of autumn, when the temperature is uncommonly 
uniform, catarrhs are sometimes quite epidemic. Long-continued observa- 
tions on the thermometric, hygrometric, and electrical conditions of the 
atmosphere, in connection with catarrhal invasions, might perhaps explain 
these apparent anomalies. Yet I have been tempted to conjecture that 
something more than modifications of heat, moisture, and electricity, is in 
(occult) action in the case ; and since the remarkable facts observed by 
Schonbein, in connection with the presence in the atmosphere of what he 
has called ozone, the conjecture has been strengthened. It may be that the 
sensible changes are not the immediate causes, but that they produce some 
isomeric modifications in the atmosphere which do the mischief, and this 
(conjecturally) may be the reason why the apparatus of respiration suffers 
more than all other parts of the organism. 



SECTION II. 

MISCELLANEOUS CAUSES OF PULMONARY INFLAMMATION. 

If the inquiry in which we are engaged were limited to the causes of 
simple acute pulmonary inflammation, we might stop here ; but as it em- 
braces the chronic, whether simple or tubercular, we must extend it to 
other agents which are known, or supposed, to be injurious. We begin 
with 

I. Cotton-Fuzz. — As the southern portions of the Interior Valley pro- 
duce and prepare for market the larger part of the cotton used in Europe, 
and moreover supply the whole United States ; and as the manufacture of 
that staple is increasing throughout the Valley, it is important to ascertain 
the effects of its fuzz on the respiratory apparatus ; this I have endeavored 
to do, but have not been as successful as I could have wished. 

The gin is a machine of rapid motion for eliminating the seed from 
cotton. It throws an immense amount of broken fibres or fuzz into the 
atmosphere, which are of necessity taken into the lungs of those who con- 
duct the operation, who are generally negroes. The period of ginning does 



800 THE PRINCIPAL DISEASES OF THE 

not last very long, nor are a great number of operatives necessary to the 
management of a gin. When travelling in the South, I learned that pro- 
prietors do what they can to promote ventilation, avoid their gin houses, 
and avoid employing men who are predisposed to pulmonary disease, and 
often change them, so that no one shall inhale the fuzz very long. These 
precautions indicate, as the public opinion, that it may do harm, as indeed 
it undoubtedly does, but to a less extent than might perhaps be expected. 

Dr. Harrington, formerly of North Alabama, informed me, that he had 
observed the cotton-ginners to be affected with a kind of bronchial consump- 
tion, which was attended with a thin yellowish expectoration. He had seen 
three fatal cases. Dr. Ames, of Montgomery, in South Alabama, writes 
me : " I have made inquiry as to the effect of cotton-ginning on the lungs, 
and find that it almost always produces an increased secretion from the 
lining membrane of the air passages, from the nose downwards, with a cough, 
a disorder which the planters call a cold. It is so slight, however, that a 
physician is rarely consulted, and it generally passes off as soon as the gin- 
ning time is over. I do not remember to have been applied to on account 
of it more than twice, and then the complaint was a very mild bronchitis. 
I have been informed by one of the oldest and largest planters in this 
county, that he owns a negro, who has ginned for him a great many years, 
and is now a very healthy old man. The physicians in this town and its 
vicinity agree, that the ginners are not more liable to serious diseases of the 
lungs than other negroes." In the Session of the University of Louisville, 
for 1846-7, I desired such of the students from the cotton zone, as knew of 
any facts bearing on this subject, to communicate them. Five responded to 
the request. Mr. T. W. M'Leroy, of Tuscaloosa, Alabama, knew a negro 
man, of well-developed chest and sound lungs, who had for ten years been a 
cotton-ginner, every winter for three months. The occupation did not 
appear to produce actual bronchitis, but he was affected during the winter 
with irritation and increased secretion from the mucous membrane. Mr. 
W. Taylor, of Talladega, in the same State, is quite certain, that in the 
region where he resides, those who continue long at this employment are 
seriously injured, becoming affected with bronchitis, asthma, and phthisis. 
His preceptor, Dr. M'Cazie, has had many such patients. Mr. W. A. 
Pegues, also, of the same State, has seen many cotton ginners seriously 
affected in their lungs by that occupation. In some cases actual bronchitis 
has been produced. His father, an extensive cotton-planter, has long been 
so well satisfied of the fact, that he has adopted the rule of frequently 
changing the hands employed about the gin, so that no one shall breathe 
the impure atmosphere more than a few weeks. Mr. W. J. Dupree, of 
Mississippi, has never observed any other ill effects from ginning, than a 
slight catarrhal affection, accompanied with a hacking cough, which passes 
away soon after the season is over, leaving the individual in as good health 
as he was before. He knows a negro man who has attended the gin more 



INTERIOR VALLEY OF NORTH AMERICA. 801 

or less every winter for fifteen or twenty years, and remains quite free from 
pulmonary disease. Such cases lie thinks are not rare. Mr. A. E. Thomas, 
of the same State, says, " This subject is one of great interest with all our 
intelligent planters, as the effect of cotton-ginning on their negroes is very 
deleterious; so injurious, indeed, as to be obvious to the negroes them- 
selves, who endeavor to avoid the gin-house. Planters select their oldest 
and least valuable negroes for this occupation, knowing that the healthiest 
and most robust will, in a year or two, become diseased. To prevent 
these bad effects, it is not uncommon to make them wear and breathe 
through a veil, and give them molasses and water to drink, measures which 
appear to be generally effective. If a person not accustomed to breathe 
the air of a gin-house, goes into it while the machine is running, he is soon 
seized with a tickling sensation in his nostrils, followed by sneezing, cough- 
ing, and some degree of hoarseness. Continuing awhile in this situation, he 
begins to feel his nostrils stuffed up. After leaving the place he will have 
symptoms of a cold for several days. Remaining longer there, the stuffing 
of his nostrils may become so great as to prevent his breathing through 
them. The cough attendant on this affection is often dry, or small quanti- 
ties of mucus, in which the lint and dust floating in the air have been 
entangled, will be thrown up. A feeling of soreness pervades the trachea 
and bronchial tubes. I have known several to have chronic bronchitis. I 
saw one death preceded by the discharge of an abscess from the lungs, and 
another die of phthisis, following on bronchitis. It is the custom every 
two or three weeks to stop the hands from field labor, to bale the gin and 
cotton, at which they are commonly occupied two or three days. .Before 
the end of this period they are apt to become affected with sneezing, cough- 
ing, and other catarrhal symptoms, which often continue for several days/' 

It appears from these various statements, that a cotton catarrh or bron- 
chitis is a reality in the South ; but that the constitutions of some of the 
operatives either resist the irritation of the fuzz or become reconciled to it, 
as happens with the inhalation of an atmosphere impregnated with chlorine; 
or the emanations from a coal fire, which often for a time excite coughing, 
dyspnoea, and headache in the unaccustomed, and then lose their effect. 

II. Hemp mills abound in Kentucky, and the operatives are both white 
and black. Hemp is also manufactured in several of the penitentiaries of 
the States south of the Ohio. 

[I think it proper to insert the following extracts from letters written 
to the author, evidently in answer to inquiries propounded by him. — Ed.] 

Dr. Jno. A. Ingles, of Paris, Kentucky, says : " From all that I have seen 
and heard from those who have enjoyed ample opportunities of making ob- 
servations, I am impressed with the belief that hemp fuzz has but little effect 
in exciting disease in those who are even constantly exposed to its influence. 
I have heard a gentleman of age, who has been nearly all his life engaged 

VOL. II. 51 



802 THE PRINCIPAL DISEASES OF THE 

in the manufacturing of hemp, say that he believed that negroes, employed 
from year to year in hemp factories, are, on the whole, more healthy than 
they would be in any other situation. " 

[The following memorandum is by Dr. Drake. — Ed.] 

Mr. Wm. M. Walker, of Cincinnati, who has been an owner of both 
cotton and hemp manufacturing establishments on the banks of the Ohio, 
has assured me that the cotton atmosphere is more insalubrious than the 
hemp. Indeed he regards the latter as nearly innoxious. 

Dr. Gr. W; Bayless, of Louisville, in a letter dated March 9th, 1845, 
writes : "This establishment (the Louisville Hemp Manufactory) has been 
in full operation since January, 1840, during the whole of which time I 
have attended to all of the black hands, and a few only of the white. The 
blacks have averaged about 60 or 70, and the whites about 30 or 40 in 
number." 

" In the course of the five years and better which have elapsed, besides 
the ordinary diseases of the seasons, I have met with two cases of phthisis 
which proved fatal; one case of hemoptysis; one of dyspepsia, attended 
with troublesome cough, of considerable duration, and one of amenorrhoea." 

"The first case of phthisis occurred in a young negro man, nearly full 
negro, about twenty years of age, who worked in the first machine depart- 
ment, where there is a good deal of dust, and which was not at that time 
well warmed. His father and mother are still living, quite old and healthy. 
He had a half brother who once had a troublesome cough, lasting a year or 
more, whilst engaged in rope-spinning; but he still continued at that work, 
and is yet a stout man, after having been engaged at it for fifteen or twenty 
years. He also had a full brother, who, when about three or four years old 
had scrofulous enlargements and suppuration of the cervical glands; but, who 
recovered from it after several months, and is now a stout boy of fifteen 
years." 

" The subject himself had always been entirely healthy, and was about 
five feet six ; compact, and more than ordinarily muscular. He was uncom- 
monly free from the vices of such boys. When he had been engaged about 
six months in the occupation spoken of, he was seized with acute phthisis, 
and died in about three months. No post-mortem examination was made." 

" The second case of phthisis occurred in a negro boy (full negro) about 
ten years of age. I know nothing of his parentage or history. Before his 
attack, he was about as stout as negro boys generally of his age, and pre- 
sented no indications of delicate constitution that I am aware of. He was 
engaged in the spinning department ; but I am not able to say how long he 
had been there ; it was either three or fifteen months ; and I am inclined to 
think the former. In March, he was seized with symptoms which at first 
looked like mild pneumonia, but in three or four weeks, it became manifest 
that the disease was acute phthisis; and in between two and three months 
he died. No post-mortem was made for want of an opportunity." 



INTERIOR VALLEY OF NORTH AMERICA. 803 

" Besides these, there is a man engaged in hatchelling. He has been at 
it for two or three years; and frequently complains of pain and oppression 
of the chest, attended with hoarseness, amounting almost to aphonia. But 
he still continues stout and able to perform his laborious work." 

" The boy already spoken of, who had, when a child, scrofulous affection 
of the cervical glands, is also subject to a similar hoarseness if put at spin- 
ning, or any work which exposes him to much dust. He has been put to 
reeling rope, where there is but little dust, and he remains free from the 
hoarseness." 

Dr. TV. C. Sneed, of Frankfort, Ky., observes: " By reference to the 
case-book in the Penitentiary, I find that thirty-four patients have entered 
the Hospital during the last three years with disease of the lungs, viz. : 
pleurisy, pneumonia, and bronchitis, and that all of these, with the excep- 
tion of one, came from the hemp shops. There are, on an average, ten men 
employed in hatchelling, fifteen in weaving, &c, and from thirty-five to forty- 
five in spinning. With the exception of diseases of the lungs, I do not per- 
ceive any difference in the number of admittances from the various shops. 
The hemp business gives nearly all the cases of disease of the lungs, and 
an equal proportion of other diseases. I perceive that all the cases of 
typhoid fever from the hemp-shops, have had bronchitis more or less during 
the course of their attacks. I find it often necessary to change individuals 
with weak lungs from the hemp-shops to other employments. We find that 
all persons threatened with, or actually laboring under, bronchitis or tuber- 
cles, have to be put at some other employment. The weaving and hatchel- 
ling seem to be the most unhealthy branches of the hemp business ; the 
latter the most so, from the excessive quantity of particles continually float- 
ing in the atmosphere. None but the most healthy are able to labor in 
either of these branches, and when threatened with any difficulty in the 
lungs, they are immediately changed, and their places supplied by others. 
I am decidedly of opinion that but few men could withstand the effects of 
the dust in the hatchelling-house more than one or two years." 

III. Our Interior Valley abounds in flour and grist mills, the atmospheres 
of which are thickly impregnated with impalpable powders, chiefly amyla- 
ceous. The phrase, " only a miller's cough," embodies popular observation 
in regard to these atmospheric impurities. They irritate sufficiently to ex- 
cite coughing, but not, of themselves, to generate inflammation. Perhaps 
they may predispose to chronic bronchitis J and quite as likely may become 
an exciting cause of tubercular inflammation. 

That catarrhal affection, denominated hay-asthma, has been ascribed to a 
floating farinaceous powder, the pollen of the grasses, cultivated for hay. I 
have seen but two cases of it, and both had annual returns, not at the time 
of our hay harvest, but in August, when our Indian corn (Zea maize), ano- 
ther grass, remarkable for the amount and strong odor of its pollen, is in full 
flower. These patients, however, were not agriculturists, but inhabitants 



804 THE PRINCIPAL DISEASES OF THE 

of towns ; and I am not at liberty to ascribe their disease to such a cause, 
for in a country where Indian corn may be said to have replaced the forest, 
the annual impregnation of the atmosphere with pollen, would, if it were 
the cause of that malady, be likely to occasion a greater number of cases 
than occur, even admitting the necessity of a remarkable idiosyncrasy, as 
the predisposing cause. I have mentioned that, as a physician, I have seen 
but two cases; and may add, in further evidence of its rarity, and as 
strengthening the conclusion just expressed, that during my corn-field labors 
for many years in early life, I never saw a case. 

IV. Mineral Impurities. — Respiring an air laden with mechanical 
impurities from the mineral kingdom, though not a cause of acute, may pro- 
duce chronic mucous inflammation. But all impurities do not have this 
effect. Street dust consisting chiefly of comminuted clay and limestone, 
and the dust of charcoal and stonecoal, appears not to be capable of ex- 
citing inflammation, though its repeated inhalation may slowly establish in 
the lungs an organic lesion, as the spurious melanosis in those who work in 
coal. The dust of millstones, consisting chiefly of angular particles of silex, 
is mechanically irritating, and may occasion mucous inflammation, or pro- 
mote the deposit of tubercle in the predisposed. There are but few esta- 
blishments of this kind in the Valley. Stone-cutters' yards are numerous, 
and their atmospheres would abound in hard particles of carbonate of lime 
and sand, were the operations with the chisel not generally conducted in the 
open air, by the currents in which they are blown away. 

In certain places around the northern Lakes and the Gulf of Mexico, there 
are dunes, in forming which, and from which, the wind drifts into the atmo- 
sphere great quantities of fine sand. Some of these localities have been 
charged with producing pulmonary diseases, among which we might expect 
to find subacute bronchitis. When visiting Pensacola Bay, where every 
breeze raises great quantities of white sea-sand, I did not meet with any con- 
clusive evidence of its pernicious influence on the lungs, though it is a fact 
that many persons die of consumption at that place ; not a few of them, 
however, emigrate from places further north for the purpose of arresting or 
warding off that malady. When travelling in the North, I was assured by 
Judge Lane and Dr. Tilden, both of Sandusky City, but formerly of Nor- 
walk, that diseases of the lungs were more prevalent in the latter town than 
any other on the south side of Lake Erie. Judge Lane had indeed left it 
expressly for the purpose of arresting a subacute mucous inflammation of 
the respiratory passages. This prevalence they ascribed to sand ; the town 
being built on a long sand ridge, from which the wind drifted and deposited 
great quantities in all the houses. When I visited that beautiful village, 
I found the topographical account of those gentlemen correct; but Dr. 
Baker and Dr. Kilteridge flatly denied that there was, or ever had been, any 
special prevalence of pulmonary disease among its inhabitants. Subse- 
quently I visited Painesville, built on a continuation of the same sand ridge; 



INTERIOR VALLEY OP NORTH AMERICA. 805 

but could not learn that either chronic bronchitis or phthisis was more pre- 
valent there, than in localities having an argillaceous surface. 

V. Gaseous Impurities. — As these are chiefly found in manufacturing 
cities, they do not of course often injure the lungs in a newly settled country 
like ours. Pittsburg and Cincinnati are the only cities in which the chemi- 
cal manufactures are carried on to any considerable extent. Carbonic acid 
gas and carburetted hydrogen are those to which we are most exposed * but 
they kill by a species of narcotism, and not by inflammation. On the other 
hand, nitrous acid vapor, ammoniacal gas, phosphorous acid, gaseous hydro- 
chloric acid and chlorine, are inflammatory irritants to the bronchial mem- 
brane. The last, however, has a slightly narcotico-sedative property, under 
the influence of which it gradually diminishes in its irritating effect on that 
membrane.* The whole of these gases are developed in the manufacturing 
establishments already erected among us, and as they increase in number, 
these causes of laryngeal and bronchial inflammation will multiply. 

VI. Flame, or gases in a state of combustion with a mixture of atmo- 
spheric air having the same temperature, it is supposed may be inhaled and 
burn the bronchial membrane. This, as far as I know, has not been demon- 
strated by post-mortem inspection. I have seen a case in which the flame 
surrounded the head and face, the patient being in bed ; it proved fatal in 
less than twenty-four hours, without an external burn, sufficient apparently 
to occasion death • but as no dissection was permitted, it remains uncertain 
whether the flame entered the glottis. 

A far more common accident is exposure to hot steam, by the bursting 
of boilers in our numerous boats and manufacturing establishments. That 
a scalding of the aerial passages above the rima glottidis may happen in these 
accidents is unquestionable ; but I doubt whether it extends into the lungs, 
for steam brought in contact with any solid substance, loses its caloric with 
remarkable quickness ; and, indeed, the loss of heat under mere expansion 
and diffusion is exceedingly rapid."}* 

VII. Mechanical Violence. — Punctured and gun-shot wounds, no 
uncommon lesions in this country, fall largely on the lungs, and of course 
excite inflammation ; blows or falls on the chest may be followed by the 
same result, especially when a rib is fractured; employments which keep 
the thorax unnaturally bent or confined, may, at least, predispose to that 
effect, as may the lifting of heavy weights, or inordinately exercising the 
vocal organs. 

* Christison on Poisons. 

t In the year 183- the steamer Flora burst her boiler, on approaching Cincinnati. I had an oppor- 
tunity of inspecting the condition of a large number of the scalded, and found in every instance, that 
the slightest covering had been a sufficient protection. In penetrating it the steam had lost so much 
of its heat as not to scald. This fact should instruct passengers to keep their bodies well protected at 
night with personal clothing, and to make the covering of their faces a first instinctive act, in the event 
of an explosion. Those however who might happen to be near the boilers would no doubt be scalded, 
for the great heat of the issuing vapor would raise their clothing to the temperature necessary to that 
effect.— (West. Jour., Cincinnati.) 



806 THE PRINCIPAL DISEASES OF THE 

The last, although the lungs would seem as much tasked, shows its effects 
chiefly in the larynx. The disease thus induced or apt to arise in our public 
speakers, especially in preachers of the gospel, has in latter years appeared 
to be increasing. It is generally subacute or chronic, but may be aggravated 
into an acute inflammation. I have seen many cases of this affection, and 
relying entirely on observations made in this country, have come to the fol- 
lowing conclusions as to its predisposing and exciting causes : First, inordi- 
nate exercise of the vocal organs, especially in the open air, which calls forth 
greater effort, is one. It leaves the larynx in a state of enfeeblement and 
morbid sensibility; which is augmented by repetition, until reaction in the 
form of inflammation occurs. But the former may be only a predisposing 
condition, which atmospheric changes, otherwise harmless, transform into 
inflammation. This kind of preaching, however, was more practised in 
former than latter times, and yet the malady prevailed less then than now. 
The explanation of this anomaly is to be found, I think, in the almost uni- 
versal custom in years gone by of drinking whiskey and water, or smoking, 
or both, when the exercise of the organ was over. It was thus relieved 
from its debility and irritation, the predispositions to inflammation. Holy 
convictions of duty, in reference both to precept and example, have for the 
last twenty-five years, restrained our clergy from these preventive measures, 
especially the first; while their less scrupulous brethren of Great Britain 
and Ireland, have continued to practise them, and thereby (in part) escaped 
the disease. Second. In the earlier periods of the settlements of this 
country our clergy led more active lives than latterly. A scattered popula- 
lation required them to ride much on horseback, and the exigencies of a new 
country demanded personal labor, more than the tastes of the people called 
for highly wrought sermons. This kind of life gave a vigor of constitution 
in which the larynx participated, and consequently it could perform a great 
deal of labor without falling into disease. It might be supposed that our 
clergy would, as a hygienic measure, devote a part of their time to manual 
labor in the open air, or to the cultivation of those natural sciences, which 
require excursions on foot, but such, as a general fact, is not the case. The 
Methodist Episcopal preachers, it is true, are of necessity itinerants, but all 
others, with exceptions of course, spend much of their time in their studies, 
or in school-rooms as teachers, and thus impair their usefulness, by ill- 
judged efforts to increase it. Third. Many young men are thoughtlessly 
put to the study of theology, when they are infirm, or even predisposed to 
pulmonary disease, and pass through the period of professional education, 
as they had passed through the academical or collegiate, without taking more 
than what may be called a minimum of exercise. Thus they come into the 
ministry with such feebleness of constitution or such impending tuberculiza- 
tion of the lungs, as soon puts an end to the functions for which they had 
intellectually and morally, but not physically prepared themselves. 

If there be, as I believe there is, a reality in these causes, it is unneces- 
sary to look for others, as they are adequate to the effect. 



INTERIOR VALLEY OP NORTH AMERICA. 807 

VIII. Pathological Causes. — Pericarditis sometimes extends into the 
lungs and produces partial pneumonia. The same disease may be produced 
by suppurative inflammation of the liver. Burns or scalds on the thorax 
may be followed by pulmonary inflammation. Pharyngitis, either simple or 
scarlatinous, may dip into the larynx, and the latter sometimes generates 
pneumonia. The typhous fevers very often originate the same disease. In- 
flammatory dyspepsia and chronic hepatitis frequently awaken subacute 
bronchitis. A chlorotic state occasionally invites tubercular inflammation. 
The two great modifying causes of pulmonary inflammation are, moreover, 
in a certain sense pathological. They are the typhous and the malarious 
diatheses to which reference was made in a preceding chapter. 

[The enormous and unprecedented development of arts and manufactures 
in the Interior Valley has doubtless added very largely to the sources of 
pulmonary disease. Among the occupations not alluded to by the author, 
but now very extensively carried on, in which the air inhaled by the work- 
men is much contaminated by the presence of mechanical impurities, may be 
enumerated coal and other mining and quarrying, moulding, brass-founding, 
edge tool and gun-barrel grinding, pearl and horn button making, wool card- 
ing, starch making, and attending on some of the patent planing machines. 
The manufacture of bone and ivory-black, and other forms of animal char- 
coal, and that of felt hat bodies, should also be mentioned here. — Ed.] 



CHAPTER XII. 

MUCOUS INFLAMMATIONS OF THE RESPIRATORY ORGANS— CATARRH, 
—INFLUENZA— LARYNGITIS, ACUTE AND CHRONIC. 



SECTION I. 

ENDEMIC catarrh. 

I. Symptoms and Pathology. — It is almost a solecism to place this 
affection among the phlegmasia ; yet no other association could be so 
proper. A detailed history of its symptoms is unnecessary. It generally 
begins in the mucous membrane of the nares and collateral cells, with 
sneezing and a sense of fulness and dryness, soon followed by increased 
secretion, giving the defluxion from which its name is derived. The dis- 
charge, always watery in the beginning, is sometimes so acrid as to exco- 
Tiate the upper lip. An increased secretion from the conjunctiva is not 
uncommon. The constitution is but little disturbed ; but in some cases 
there is a sense of chilliness alternating with febrile flushes. This simple 



808 THE PRINCIPAL DISEASES OF THE 

congestion, relieved by increased secretion, and constituting the corjza of 
the nosologists, often constitutes the whole of a catarrhal attack ; but more 
commonly the irritation and congestion pass down to the rima of the glottis, 
when they abate in the anterior passages. Coughing, from a tickling sen- 
sation in the organ, now replaces the sneezing. At first the cough is dry, 
but a moderate expectoration of mucus soon commences. Having continued 
in the larynx a day or two (more or less), the irritation and congestion, 
apparently without attacking the trachea, manifest themselves in the bron- 
chial tubes, first by a sense of fulness, constriction, slight dyspnoea, and 
soreness, with cough and sparing expectoration. Increased secretion of 
mucus, however, soon supervenes, and contributes to mitigate the symptoms, 
which in many cases do not pass away without the occurrence of a little 
fever and sense of languor or weariness. This is a bronchial catarrh. It 
is worthy of note, that the spread of catarrhal congestion is generally from 
without inwards ; and so constant is this law, that when it begins in the 
larynx, the nares are scarcely ever affected, though it very generally de- 
scends into the bronchi; and when it commences in those tubes, it seldom 
affects the apparatus above. 

The same amount of irritation and hyperemia which is present in 
catarrh, would, if it occurred in a serous or cellular tissue, immediately 
pass into inflammation. That pathological condition is averted by the in- 
creased secretion which resolves the congestion. When this does not 
happen, simple becomes active hyperaemia, and we have, if it occur in the 
nares or the cavities communicating with them, inflammatory coryza ; if in 
the outer membrane of the eye, conjunctivitis or catarrhal ophthalmia; if 
in the larynx, laryngitis ; in the bronchi, bronchitis. 

II. Treatment. — Catarrh uncomplicated with inflammation is a kind of 
self-limited disease, that is, will cease without the intervention of art, 
whenever inflammation does not supervene. A room of uniform and com- 
fortable temperature, a cathartic in the day, and a sudorific draught at 
night, with laudanum or paregoric to abate the cough, promote perspiration, 
and procure sleep, together with confinement to bed the next day, so as to 
keep up a diaphoresis, are in general all the means required. If,'.to employ 
the language of the people, the "cold should not be broken" by this gentle 
treatment, inflammation should be suspected. A well-founded suspicion of 
this kind should prompt to bloodletting, after which the same treatment 
should be continued. During the expectorating stage, a generous diet 
often gives great relief; but if inflammation should be present, it may do 
much mischief. 

In feeble and pituitary constitutions, this kind of diet is most required, 
and in some cases attended with copious expectoration, tonics, opiates, and 
the compound tincture of benzoin, must be added ; or the patient may be- 
come greatly reduced by the excessive secretion. 

III. Consequences. — The greatest interest in this disease results from its 



INTERIOR VALLEY OF NORTH AMERICA. 809 

being in popular phraseology a cause of consumption, many cases of which 
are distinctly traced up by the patient or his friends to his taking cold. 
He will say that he is "easy to take cold :" that as he gets well of one he 
is attacked with another. Now in every case of this kind, there is a tuber- 
cular diathesis, which predisposes to catarrh, and that little malady in turn 
becomes an exciting cause of tubercular inflammation of the lungs. If 
there should not be such a diathesis, repeated catarrhs presage chronic 
bronchitis, or non-tubercular consumption. They show an infirm and mor- 
bidly susceptible condition of the bronchial membrane. 

The disease we have briefly considered results from indigenous causes, 
which may act on a single person, giving a sporadic disease for on many at 
the same time, when it prevails accordingly, and constitutes an endemio- 
epidemic ; it is then very commonly called influenza, but that name be- 
longs more properly to the subject of the next section. 



SECTION II. 

INFLUENZA, OR EXOTIC, EPIDEMIC CATARRH. 

I. History. — The cause of this malady is as utterly unknown, as the 
place where any one of its invasions commenced. I am unable to say how 
often it has traversed our Interior Valley, for its vast uniformity of surface 
leads to an extensive production of the endemic disease at the same time, 
when it is generally called influenza, and the means of distinguishing it 
from that malady do not exist. It is sufficient to know that we have been 
invaded by this exotic epidemic. 

The first and greatest invasion of this kind, which I have had an oppor- 
tunity of witnessing, occurred in the year 1807. In the summer or early 
autumn, the newspapers brought the intelligence of its prevalence in 
Europe, and afterwards that it had reached our eastern cities. It was in 
October, when the weather was fine and steady, that it appeared in this 
locality. Two regiments of militia, called into the field to repel from our 
frontier a threatened invasion of Indians, were at the time encamped a few 
miles out of town, and I was then in attendance upon them. These men 
were its first subjects, the people of the town still being healthy. In a few 
days, however, it reached the latter, and then sought out the scattered in- 
habitants of the country. At that time there was but little communication 
between our settlements, yet I was able to ascertain, that it "spread far and 
wide" among them. 

I need not give the history of any other prevalence, as this illustrates 
the most constant of the laws which govern influenza ; first, its progressive 
extension from east to west j second, its independence of all sensible condi- 
tions of the atmosphere ; third, its first outbreak in bodies of men, and 
compact settlements. 



810 THE PRINCIPAL DISEASES OP THE 

II. Symptoms. — "While the symptoms of this new visitant were sub- 
stantially the same as those of catarrh, there were modifications which 
deserve notice. Thus, although it often commenced in the nares alone, it 
seemed at the same time to invade the whole respiratory membrane. There 
was more fever, and the signs of inflammatory orgasm were often very ap- 
parent ; but the highest characteristic, not always present, was' a sense of 
sinking and prostration, with a serious feeling of disorder throughout the 
whole system, indicating the impress of some malignant agent. In subse- 
quent epidemics, I met with cases of the same kind ; and although they 
did not prove fatal, they suggested the idea of danger. 

III. Consequences. — Our influenzas, and especially that of 1807, left 
many bad consequences behind them, referable chiefly to defective antiphlo- 
gistic treatment, both the people and some of the physicians being unaware 
of the necessity for active antiphlogistic measures. First, in many cases 
subacate bronchitis followed j second, in others more serious forms of pul- 
monary inflammation, which in a patient of my own terminated in a sudden 
and copious expectoration of pus, but whether suppuration in the cellular 
substance of the lung, or in the sac of the pleura, I could not learn as a 
post-mortem examination was not permitted; third, but the greatest injury 
was experienced by those who were predisposed to phthisis, so that an un- 
usually large number of cases of that malady followed through the ensuing 
year, showing that influenza has greater capability for exciting that disease, 
than our endemic catarrhs, which had failed to awaken it in these indi- 
viduals. 



SECTION III. 

ACUTE LARYNGITIS. 

I. History and Symptoms. — This malady occurs sporadically in all. 
parts of our Valley, but is never, like the last two, epidemic. My im- 
pression is, that the severer forms are less common here than in Europe, for 
the number of persons who die of it is very small. The subjects of origi- 
nal acute laryngitis are generally adults, and male much oftener than female. 
Occurring as a secondary affection it may appear at any age. The diagnosis 
of the simple form of this phlegmasise, is not difficult. Fever, character- 
ized by a well-developed pulse, a hoarse, harsh, or flat cough, with but 
little expectoration; a wheezing respiration; loss of clearness and flexibility 
in the voice ; a sense of embarrassment in the larynx, with dyspnoea in- 
creased at intervals ; more or less pain, aggravated by pressure, especially 
when carried behind the thyroid cartilages; difficulty of deglutition, and a 
repugnance to the attempt, can leave no doubt as to the nature of the dis- 
ease, except when complicated with tonsillitis ; the glands, on examining 
the throat have their natural size and color, but more or less pharyngeal 



INTERIOR VALLEY OF NORTH AMERICA. 811 

redness is generally present. To complete the diagnosis, the lungs should be ex- 
amined, both by an inquiry into the rational symptoms, and by percussion and 
auscultation, special attention being given to their apices, with a reference 
to deposits of tubercle, the ascertained existence of which would suggest a 
less copious depletory treatment. 

II. Treatment. — When called early to a case presenting the symptoms, 
or a majority, which have been enumerated, this simple primary inflamma- 
tion of the mucous membrane of the epiglottis, rima glottidis, and larynx 
may generally be subdued. 

Bloodletting is, of course, the first and greatest remedy, -and should be 
carried to approaching syncope, otherwise from its detached character of 
the afflicted part, in reference to the highways of circulation, its vascular 
system will not feel the loss of blood. Immediately after such a bleeding, 
an antimonial emetic should be given. Vomiting has been thought danger- 
ous, from the inability of the epiglottis to close the entrance to the glottis 
securely ) however, this may be I have certainly never seen suffocation pro- 
duced by the act of vomiting in this disease. The associated physiological 
action between the pharynx and the stomach, is so intimate as to give to 
impressions made upon the latter great influence over the former. We have 
an example of this in the copious secretion from the throat which precedes 
vomiting. Now it can scarcely be otherwise than that this effect must extend 
to the larynx, so closely connected in anatomy with the pharynx, and so much 
affected in every act of deglutition. Purging should follow vomiting, and by 
administering tartarized antimony in a solution of sulphate of magnesia, it 
may be speedily effected. Subsequently the antimony should be adminis- 
tered in nauseating doses, combined or alternated with small portions of 
calomel, as an antiphlogistic alterant. A second venesection may be de- 
manded, and should again be carried to the verge of syncope. But topical 
bleeding is not to be overlooked. Leeches may be applied on each side of 
the larynx, except when the patient is aged, of a soft or lymphatic tempera- 
ment, or shows any signs of a hydropic diathesis, when their bites might be 
promotive of cedematous infiltration. Cupping on the nucha is not, however, 
liable to these objections, after which a blister may be applied to that part. 
Warm poultices to the larynx, and wrapping the throat with flannel, are 
common applications, but can scarcely be of other use than to exclude the 
action of the outward air, ever varying in temperature. Surrounding the 
neck with towels dipped in cold water is a practice I have not seen tried, 
but, from analogy, why should it not be useful ? The inhalation of steam 
as a means of soothing the inflamed membrane and promoting secretion, is 
a popular practice which seems to be well founded. As much as the dys- 
pnoea attending on this disease, arises from the spasmodic action of the mus- 
cles which regulate the aperture of the glottis, the exhibition of a watery 
infusion of assafoetida in mucilage of gum Arabic, might after due evacua- 
tion prove beneficial. Such are the remedies for acute, simple laryngitis, 



812 THE PRINCIPAL DISEASES OF THE 

and we must now turn our attention to complicated and more perilous 
forms. 

III. Exudative or Membranous Laryngitis is but a modification 
of the last, characterized by the production of an imperfect false membrane. 
The tender film generally extends through the rima of the glottis, and may 
be seen on inspecting the pharynx. To my own mind it is probable that 
coagulating lymph is oftener thrown out in inflammations of the mucous 
tissue than we suppose. It is washed away by the mucus, or so diluted 
by it as not to coagulate into a film. Two pathological conditions may be 
supposed to favor the appearance of this membrane ; first, an arrest of the 
mucous secretion, and second, an extraordinary degree of hyperinosis. I 
do not presume that the appearance of this false tissue is evidence of a 
specific character in the inflammation j yet this affection described under 
the term diphtherite has appeared as a local epidemic. 

[A memorandum of the author shows his intention of adding more to 
this sub-section. — Ed.] 

IY. (Edematous Laryngitis. — The variety of inflammation desig- 
nated by this term, in the writings of British and American physicians, has 
been subdivided into two by Albeus of Germany, who has bestowed on 
them the names angina epiglottidea, and angina oedema.* According to 
Halse, the first of these is an inflammation with copious infiltration of 
serum and lymph, below the mucous covering of the upper and convex 
surface of the epiglottis. The membrane of the other side being more 
closely attached does not permit areolar infiltration, and thus the organ 
becomes more convex, presenting behind a longitudinal trough or groove. 
The inflammation, however, is seldom limited to that appendage of the 
larynx, but extends to those folds of mucous membrane " which unite the 
epiglottis on the one hand to the root of the tongue, and the arches of the 
palate on the other with the larynx, especially laterally in the direction 
of the arytenoid cartilages — those folds, being, as is well known, very lax 
and movable, and susceptible of great extension." According to the same 
distinguished pathologist, there is no recorded example of oedematous infil- 
tration beneath the mucous membrane of the larynx below the glottis — 
the surface of that organ being " reddened, puffy, and covered with a puri- 
form mucous layer," while the glottis itself, and the folds above, may 
present nitrations, giving the angina oedema of Albeus. Thus the term 
oedematous laryngitis is not rigidly correct. The danger in these affections, 
is that of slow or sudden suffocation, resulting from the swelling of the 
glottis, but oftener from the descent of the swollen folds of mucous mem- 
brane above, at the moment of respiration, so as to close the rima glottidis, 
to which we should add the occasional contraction of the muscles which 
close the aperture, giving the paroxysms of dyspnoea, which occur in simple 
or uncedematous laryngitis. 

* Halse : Anat. Des. of the Dis. of the Cir. and Reap. Phil. Ed. p. 258 



INTERIOR VALLEY OF NORTH AMERICA. 813 

In the diagnosis of this variety, we scarcely have the aid of one reliable, 
differential symptom. If the tongue be depressed by the finger or a non- 
metallic spatula, of the temperature of the body, and the patient be directed 
to make a deep respiration, or a sudden effort to cough, the apex of the 
epiglottis is sometimes brought into view, under the aspect, according to 
Halse, of a dark red conical tumor, projecting behind the root of the 
tongue. The exhibition obtained by coughing is almost too momentary to 
be instructive. Stress may be laid upon external oedema about the upper 
part of the larynx, but it does not appear in every case ; and when present 
has sometimes been observed to precede the inflammation j it is not on that 
account, however, the less pathognomonic, as it shows, in the system, a 
tendency to serous infiltration, which inflammation could not fail to quicken. 
In most cases, then, the diagnosis must be drawn from the symptoms enu- 
merated under the first head, but not in reference to a greater intensity of 
those which indicate inflammation; but those which show the lesion of 
respiration. In fact the inflammation in this modification is often less 
violent than in the preceding, while the dyspnoea resulting from the con- 
ditions which have been pointed out is much greater. The common sub- 
jects of this variety are those who have infirm constitutions, or who like its 
noblest victim, our own Washington, are advanced in life. Such subjects, 
although less liable to acute inflammation with fibrinous effusion, are more 
liable to serous infiltrations. The general signs of laryngitis being present, 
a rapidly ingravescent dyspnoea, accompanied with anxiety, a disposition to 
sit up in bed, greater difficulty of inspiration than expiration, a sudden 
failure of voice, and stridulous sounds in breathing, would leave no doubt 
as to the character of the disease. But in the previous or present absence 
of the signs of inflammation, these symptoms might and should be referred 
to spasm — laryngismus stridulus. When, however, the disease is farther 
advanced, and defective aeration of the blood begins to develop a smoky 
or purple tint of the gums, lips, and other parts of the surface, the diagnosis 
is as complete as the danger is then imminent. This method of ascer- 
taining the existence and nature of morbid actions, by the ravages they 
produce, is, however, the last on which a physician would desire to rely. 

The treatment, generally successful in simple laryngitis, is by no means 
as reliable in the variety now before us ; which, although happily rare, is 
very often fatal. Assuming that the urgent embarrassment of respiration 
was a true index of the intensity of the inflammation, which, as we have 
seen, it is not, great stress has been laid upon bloodletting. 

Before any discoloration of the skin has appeared, there can be no doubt 
of the propriety of bleeding to syncope ; and there may be cases which 
would be benefited by repeating the operation ; but in feeble constitutions, 
the sudden and extensive loss of the red corpuscles may promote the serous 
effusion, which is the great source of danger. After the signs of a carbonated 
condition of the blood have appeared, a venesection may still be admitted 



814 THE PRINCIPAL DISEASES OP THE 

but should be much less copious. Of the propriety of administering an 
active emetic there can .be no doubt; for on the one hand it moderates 
inflammation, on the other promotes serous absorption. Whenever exter- 
nal oedema shows itself the parts should be punctured to effect, if possible, 
some escape of the effused serum, and to afford at the same time the benefits 
of local bleeding. Internally incisions may be made on each side of the 
glottis with an appropriate knife, as invented and practised by Dr. Buck, of 
New York. As to the rest, the treatment already pointed out will be 
proper; but unfortunately the disease is often more rapid in its progress, 
than our means of treatment in their action. 

When this is the case and suffocation is impending, tracheotomy is the 
only resource, and has sometimes proved successful even when complete 
asphyxia had taken place.* This is encouraging; but, in a country like 
ours, the greater number of physicians are not likely to be prepared for this 
operation, or at least will defer it till the time has passed b} 7 for it to be 
successful. Even the best surgeons of London, it is stated by the judicious 
Watson, have found difficulty under the incessant motion of the larynx, in 
performing the operation. 

V. Suppurative Laryngitis — Perichondritis Laryngea. — I have 
not met with a case of this modification of laryngitis, and shall therefore 
devote but a moment to it. The inflammation becomes sub-mucous, and 
according to Hasse attacks the perichondrium of the cartilages. The 
paucity of areolar tissue does not admit of serous infiltration, but the ten- 
dency is to suppuration, under which, the detached and denuded cartilages 
are sometimes discharged with the pus before the death of the patient. 
Generally secondary, the pathologist just quoted, affirms that it is sometimes 
an original affection. The object of treatment should be to prevent sup- 
puration, and that directed for the first variety would be appropriate to this. 

VI. Secondary Laryngitis. — Thus far we have considered this as an 
idiopathic inflammation, it remains to add, that it is still oftener a secondary 
affection, when although it shows less intensity, it is in some of its forms 
not less, but even more dangerous than primary. The simple inflamma- 
tions which we call tonsillitis and pharyngitis even extend into the larynx, 
or, at least, invade the epiglottis and the glottis, thus adding a dangerous 
complication to what was before painful and productive of difficulty in swal- 
lowing, and to some extent in breathing. The redness and swelling of the 
throat disclose the existence of the latter, and when by the symptoms we 
know the other to be present, we may call it secondary, for inflammation 
like catarrhal congestion, as already pointed out, has a tendency to descend. 

All the graver exanthemata may extend to the larynx, and awaken in- 
flammation ; but of the whole, according to my own experience, scarlatina 
anginosa, is most to be dreaded. I have seen many cases of that disease 

* Watson : Sect, on the Prin. and Prac. of Med. p. 508. 



INTERIOR VALLEY OF NORTH AMERICA. 815 

prove fatal "by inducing laryngeal or glottideal inflammation, and have, 
already mentioned the ulcerative erosion of the base of the epiglottis, till it 
fell over and obstructing the rirna, produced instant suffocation, in a child 
apparently far advanced in convalescence. This malady is sometimes conse- 
quent on a mercurial course, but oftener of syphilitic origin. I have seen it 
arise from organic disease of the heart, but above all it may be tubercular — 
either going before, or following, a similar affection of the lungs. That 
which results from inflammation of the throat, from erysipelas, scarlatina, 
and the other exanthems, is often acute — the other forms are more chronic. 
Of course the treatment of each must have a relation to the disease of which 
it is a part. Of the whole, the tubercular, in this country is most frequent, 
and must come up for further consideration with Phthisis. 



SECTION IV. 

CHRONIC LARYNGITIS, DISEASE OF PUBLIC SPEAKERS,* CLERGYMAN'S 

SORE THROAT. 

I. History and Diagnosis. — Acute laryngitis may degenerate into 
chronic; but the inflammation may also be subacute from the beginning. It 
is often imperceptibly ingravescent, and becomes acute, but may also be sud- 
denly raised to intensity by exposure to cold. The worst cases I have seen 
were in males who had not reached, or passed, the meridian of life. A con- 
siderable redness of the visible parts of the throat, in some cases, shows the 
presence of chronic pharyngitis. The uvula is also occasionally elongated 
and cedematous. 

The expectoration is generally sparing. The cough, always present, is 
felt by the patient to result from an irritation of the larynx, especially of its 
upper extremity. It varies much in its character. The patient frequently 
calls it a dry cough. It is sometimes hacking, at other times violent and 
spasmodic. In some cases it is hoarse and harsh, in others quite flat. Per- 
cussion or pressure always excites it, so that it is sometimes difficult to apply 
the stethoscope over the thyroid cartilages. Even a sudden inspiration, 
causing unusual expansion of the glottis, and carrying through the rima a 
rapid current of air, may bring it on. All examinations of the throat are 
apt to produce the same effect. The voice invariably suffers. The patient 
can no longer modulate it. Singing is at an end. It becomes hoarse or 
husky, then flat, and often sinks into a whisper. 

The febrile excitement varies exceedingly in different cases, and even in 

* It is unfortvinate, and still more marvellous, that this disease should have usurped the name of 
another, bronchitis. Some sciolist in anatomy, either medical, clerical, legal, or political, -who, to use 
a phrase for which our language furnishes no adequate substitute, did not know " head from tail" of 
the respiratory system, must have started it ; and as every one knows everything better than the 
structure of his own body, this nosological error has been wafted by the breath of the learned over our 
whole Valley. 



816 THE PRINCIPAL DISEASES OF THE 

the same. The pulse is generally too frequent, especially in the evening, 
but often sinks to the standard of health in the morning ; and may even 
continue in that condition for days in succession. When the inflammation 
suffers aggravation, however, the arterial excitement rises, and the pulse 
may become as intense as in an acute attack. 

The presence of these symptoms leaves no doubt as to the existence of 
laryngitis ; but to decide that it is simple and idiopathic, other inquiries 
must be made. The history of the case will show whether it be a remains 
of erysipelas, scarlatina, or any other eruptive fever ; but the most common 
complication is with pulmonary inflammation. Thus it may coexist with 
simple chronic bronchitis, or with tubercular inflammation of the lungs ; 
indeed that disease scarcely ever goes on to a fatal termination, without the 
development of both laryngitis and pharyngitis. In some cases, the larynx 
suffers before the lungs ; and the inflammation might be thought simple, 
when in fact it is specific or tubercular. The physician owes it to himself 
not to fall into error on this point. It is not sufficient, to examine the 
lungs by percussion and auscultation, and finding no abnormal sound, to 
declare that the inflammation is non-tubercular. If the patient be predis- 
posed to phthisis, and have not exercised his voice in any uncommon degree, 
is of a slender form with an elongated chest, and shows a defective nutri- 
tion, his laryngitis is undoubtedly tubercular, although the deposits in his 
lungs may not disturb his normal respiration. On the other hand, if not 
of a phthisical family or form, and if he do not show much emaciation, and 
has abused his voice, or lately experienced an attack of eruptive fever, the 
inflammation may be regarded as simple. 

Simple idiopathic laryngitis may continue for a long time. It is gene- 
rally aggravated by cold weather. At times it may almost cease, but the 
organ will still remain irritable ; and slight exposures, a hearty meal, breath- 
ing an irritating atmosphere, or making an inordinate effort of the voice, 
will awaken it. 

Our monographs and systematic treatises abound in examples of the 
diversified lesions produced by chronic laryngitis. Andral has frequently 
met with the production of false membrane.* The simple and the tuber- 
cular lesions are often mixed up together. Mucous ulceration and an 
abscess opening into the larynx, are those results of simple inflammation 
which are most common. The former are far more frequent than the latter; 
which, however, will give to the expectorated mucus the greatest purulent 
impregnation. The ulcers are generally in that portion of membrane which 
covers the vocal cords, the sacculi, the arytenoid cartilages, and the poste- 
rior surface of the epiglottis. As the disease advances, the mucous mem- 
brane generally seems to take on purulent inflammation, or the suppurative 
inflammation may extend to the perichondrium and involve the cartilages. 
With this progress, a change may take place in the type of fever, when 

* Medical Clinic ; Diseases of the Chest. 



INTERIOR VALLEY OF NORTH AMERICA. 817 

chills, evening exacerbations, and morning sweats indicate the development 
of non-tubercular , laryngeal consumption. It is now still more important 
than before, to determine whether the lungs be involved ; and if so, whether 
it be simple bronchitis or tubercular inflammation. This, happily, can be 
done with much certainty, as the signs of both these maladies, if they exist, 
will now be well developed ; and their absence will fix the hectic fever on 
the inflammation of the larynx. 

II. Regimen and Remedies. — The first point is to obviate every pro- 
ducing and exciting cause. Whether an abuse of the voice have or have not 
been one of these, a reduction in its use to the degree which is barely suffi- 
cient to express the wants of the patient is indispensable. Many persons 
suppose that to leave off public speaking or reading is sufficient, but it is 
not; for earnest conversation, even on the lowest key, may do much injury.* 
We meet with patients who carry out this self-denial till they are, as they 
suppose, quite well, and then return to their old habits. In general this re- 
produces the disease, and whenever the disease has existed for a while, it is 
better for the physician to advise a change of profession or occupation for 
life. 

Simple, idiopathic laryngitis is much influenced by the weather. A cold, 
humid, and variable atmosphere never fails to aggravate it, and is one of 
the causes which raise the inflammation into aeuteness. Here then we have 
phlegmasia of the respiratory apparatus which may be alleviated by spend- 
ing the winter in a southern climate j and this step will be as proper when 
from the progress of purulent secretion the malady has taken the form of 
non-tubercular, laryngeal phthisis, as before. 

In the early stages of this malady exercise is not proper, but after it has, 
endured long enough for the inflamed larynx to spread an enfeebling in- 
fluence though the organism, and especially after purulent secretion, with 
simulative hectic fever has commenced, exercise in the open air is of much 
value. This may be had by going South in autumn and North in spring. 
Thus without being exposed to the sudden changes of weather, the invigora- 
ting influences of exercise in the open air, in many cases so promotive of 
the cure of slow and indolent inflammations, may be obtained; and will be 
especially obvious when purulent secretion has commenced. When journeys 
are not convenient, field work, or jaunts on horseback, or in-door labors in 
dry apartments free from atmospheric impurities may be substituted. 

In the earlier stages a rigid diet is required ; but in the more advanced, 
when hectical symptoms show themselves, it may be more generous. 
Throughout the whole, milk will be proper. 

The question often comes up whether smoking is injurious. I know of 
no facts going to show that tobacco smoke, either produces or aggravates in- 
flammation, and therefore see no reason for its prohibition. If, however, 

* [I cannot refrain from here expressing a Tery decided opinion, that absolute silence for several weeks 
should in all cases be insisted on, and the patient he confined to bed. — £d.] 

vol. ii. 52 



818 THE PRINCIPAL DISEASES OF THE 

the patient be within the dyspeptic period, or have gastric symptoms with a 
spare habit, he should on that account discontinue the practice. 

"We come now to the medications. I have seen many cases of chronic 
laryngitis, which at times required copious venesection, the blood being 
buffed and sometimes cupped. In general, however, small bleedings are 
sufficient. In country practice, they may be substituted for leeching, which 
in truth often fails to afford the same advantage as such bleedings. In 
every stage of the disease an occasional vomit is beneficial. When there 
is an unmistakable inflammatory diathesis, and we feel well assured that 
there is no tubercular tendency, a gentle mercurial course may be prescribed. 
A pill of one grain of calomel and two of squill, may be administered night 
and morning, until a slight affection of the mouth is produced. Of medi- 
cines designed to change the type of action in the larynx, and relieve the 
inflamed membrane by promoting secretion, the following formula is equal 
to any I have seen used : — 

It. — Mucilage of Gum Arabic, .... ^viii. 

Tincture of Digitalis, . . . . gij. 

Tartarized Antimony, .... ^ij. — Mix. 

Half an ounce to be given from three to six times a day. When the 
cough is teasing or spasmodic the addition of four drachms of paregoric or 
one of laudanum may be made to this mixture, or a composing dose of 
either, added to the bedtime draught. As an aperient when required, a pill 
c omposed of equal parts of blue mass, squill, and compound extract of 
colocynth is one of the best. If hectic fever with night sweats should super- 
vene, the bark, and opium in large quantities, will be proper. We must 
mow turn to the local treatment. In all cases the uvula should be ampu- 
tated near its extremity, if it should be elongated or clavate. This condi- 
tion may be and often is consequential on the laryngitis, at other times con- 
temporary with it, but whatever may be its origin, its action on the epiglottis 
is that of an irritant. In common with other physicians I have considered 
the nitrate of silver the best application to the affected organ. If used in 
solution it should have the strength of half a drachm, or a drachm to the 
ounce of distilled or rain water. Many physicians, forgetting, how much 
of it is decomposed by the muriates of the mucus, use a solution too weak 
to produce any great effect. To meet the tastes of different patients, and 
the limited resources of country physicians, it may be well to mention the 
different modes of application invented by those who have made laryngeal 
diseases a special study. One of the least objectional to the patient is to 
inject the solution through a curved tube with small perforations, having 
the syringe half filled with air, resting above the medicine so as to scatter 
it over the glottis ;* another is to attach a piece of soft sponge or a mop of 

* Trousseau and Belloc. 



INTERIOR VALLEY OF NORTH AMERICA. 819 

cotton yarn to a bent rod,* or the end of a finger of a glove drawn on the 
finger of the right hand,f which, dripping with the solution should be 
momentarily pressed upon the glottis ; another is to use a smaller sponge 
and press it through the chink into the larynx ;J finally the caustic may be 
finely powdered with loaf-sugar, in the proportion of one to six or eight 
grains, and then lodged within one extremity of a small and short tube, the 
patient taking the other in his mouth, and after a perfect expiration, hold- 
ing his nose, and making a sudden inspiration, whereby the powder will be 
drawn back and fall upon or through the glottis. § If at any time any of 
these applications should seem to have been too strong, the caustic may be 
decomposed, by throwing after it a solution of muriate or sulphate of soda. 
The immediate effect of these applications is coughing with increased ex- 
pectoration, the more remote and permanent the subdual or abatement of 
the inflammation, and the cicatrization of the ulcers. 

The inhalation of various gases and vapors has been employed in this 
affection. 

External applications are not to be neglected in this malady; leeching, 
when convenient, should be employed, but will do little good if the arterial 
excitement should be high. Wearing a wet towel round the throat and 
neck is no insignificant remedy. The water in which it is dipped should 
not be very cold. Small blisters, so managed as to be followed by a free 
discharge, do good. Pustulation with tartar emetic ointment or croton oil, 
kept up for some time, is serviceable. Lastly, a seton has been found useful, 
but I have not employed it. 

Such are the chief hygienic and medicative means which have proved 
beneficial in simple chronic laryngitis. That they often fail is certain, but 
in such cases there is generally a lurking tubercular diathesis, of which I 
shall say something hereafter ; or the disease is secondary, and kept up by 
lesions of the heart or great vessels. 



SECTION y. 

LARYNGO-TRACHEITIS, CYNANCHE TRACHEALIS, OR CROUP. 

I. History, Diagnosis, and Pathology. — Croup in this country pre- 
vails most in spring and fall, when, like catarrh, it sometimes approaches to 
epidemic prevalence. But there is another period in which it frequently 
occurs. This is the month of June, when in the middle latitudes of the 
Valley, the early portion of the night has become so hot that the windows 
of sleeping rooms are thrown open, while the surface of the earth is not 
yet heated to any great depth, and the radiation of caloric renders the 

* Trousseau and Belloc. f Cusack. t Green. § Bell. 



820 THE PRINCIPAL DISEASES OP THE 

latter part cool and damp. Such an atmosphere, acting, as it is too often 
permitted to do, on the naked skin of the sleeping child, awakens this dis- 
ease. The same exposure excites cholera infantum in others ; and hence I 
have often seen the two prevailing as full epidemics at the same time. 

The symptoms of this affection are chiefly those of laryngeal inflamma- 
tion; but post-mortem inspections have shown, that the trachea is also 
implicated in fatal cases ; and hence the propriety of designating it by a 
term expressive of inflammation in both organs. 

No satisfactory explanation has been offered of the greater frequency of 
this disease in childhood than adult age. But we must recollect that setting 
aside convulsive diseases, most of the maladies of children are inflamma- 
tory. Even cholera infantum, unlike the cholera morbus of adults, is often 
attended by gastritis. Yet why should croup be more frequent compared 
with the other phlegmasia in children than adults? This may perhaps 
be accounted for by referring to its remote cause, atmospheric changes. 
The child is generally kept secluded from these, till its intelligence and 
bodily capabilities enable it to go at large — after the first or second year, 
for example, — when exposure to that which it had not been accustomed to 
meet is likely to awaken inflammation. Previous to the age of which I 
have spoken, the disease is less frequent, and after the fifth or seventh year 
it rarely occurs. In our vernacular expression, the constitution has become 
hardened. In support of this suggestion, I may refer to the fact, that those 
children, who, sufficiently clothed, are from infancy exposed to the external 
air, without much regard to its condition, and are not lodged in heated 
rooms, are least liable to croup. 

[It has always struck the Editor that, in studying the relative liability to 
disease of different ages, too little attention is paid to the comparative anatomy 
of infants, children, and adults; and the inquiry which the author has here 
attempted to answer, suggests the following cause. The larynx and glottis 
do not develop in harmony with the rest of the child, but remain much 
smaller in proportion ; there being comparatively but little difference in the 
size of these organs in a child ©f three and one of twelve years of age, 
while at the approach of puberty the aperture of the rima glottidis acquires 
in less than a year, a double extent in males, and in females is enlarged in 
the proportion of 7 to 5. Now unquestionably an amount of encroachment 
on the lumen of the glottis — whether from simple inflammatory engorge- 
ment, infiltration of tissues, or the presence of false membrane — that would 
scarcely interfere with breathing in the one case, must seriously, not to say 
dangerously, do so in the other. Membranous, exudative, or diphtheritic 
laryngo-tracheitis, I hold to be a comparatively rare disease ; the very large 
majority of the cases called croup being examples of simple mucous inflam- 
mation, where the consequent narrowing of the chink of the child's glottis 
(previously only half the comparative size of the man's), and the conse- 
quent increased irritability leading to spasmodic narrowing of that chink 



INTERIOR VALLEY OF NORTH AMERICA. 821 

from the presence or passage of portions of exuded matter, or of even 
simple mucus, give rise to a train pf symptoms, necessarily all but peculiar 
to the child, and known by the familiar name in question. Were the man's 
glottis as small in proportion, he would, cdeteris paribus, be as often the 
subject of so-called croup. 

The crowing or cronpy inspirations in certain forms of hysteria afford an 
additional illustration of the influence of the relative size of the glottis, or 
the relative liability of age and sex to the class of morbid phenomena 
under consideration.] 

The first symptoms are often but those of coryza and laryngeal catarrh 
in its early stages, — a hoarse cough, with a loud but not sharp laryngeal 
respiration, and but little fever. In this stage it is, on the whole, not 
difficult to arrest j but in some cases it begins in a less equivocal manner, 
in others passes rapidly on to a more acute stage. The cough and breathing 
become sharp and ringing; the vocal cords seem increased in tension, and 
the rima of the glottis narrowed. At the same time the mechanical part 
of respiration is performed with increased effort. This change would not 
of itself, however, establish the existence of laryngitis. A superadded 
fever is necessary to the completion of the diagnosis, and when that is pre- 
sent, there can no longer be any doubt as to the condition of the patient. 

As yet, the tracheal inflammation has not declared itself, though it may 
have existed from the beginning. It may even have preceded the laryngeal, 
though from the analogy of catarrh, as well as from the greater vital endow- 
ment and function of the larynx, that organ is probably affected first. With 
the progress of the disease, often frightfully rapid, the trachea comes to 
augment the dyspnoea, by sending up, with the inspired air, in breathing 
and coughing, detached fragments of fibrinous exudation, in the form of 
imperfect false membrane, which co-operate with those of the larynx in 
mechanically obstructing the rima of the glottis, and increasing the danger 
of slow suffocation. Or the trachea itself may be the seat of obstruction, 
from agglomerations of the same membrane, aided, perhaps, by a certain 
degree of spasmodic constriction at the same point. Under these circum- 
stances, the movements of the muscles of respiration become more violent 
and convulsive, from the instinctive efforts of the little patient to introduce 
air into the lungs. 

The inflammation is often limited to the larynx and trachea, but several 
writers have of late insisted on its frequent extension to the bronchial 
tubes, and even to the vesicular and areolar structures of the lungs, in the 
form of bronchitis and pneumonia. The reality of this has been shown, in 
Europe, by post-mortem inspections; but, for the last thirty years, even 
without the aid of the knife or the stethoscope, many of our own physi- 
cians, guided by the symptoms only, had come to the same conclusion. 
Thus, as far back as 1820, the late Professor Richardson, of Transylvania 
University, was accustomed to teach his pupils, that inflammation of the 



822 THE PRINCIPAL DISEASES OP THE 

thoracic portions of the pulmonary apparatus, are frequent complications of 
croup. The actual detection of such complications is not an easy task, for 
children are generally alarmed, restless, and disposed to cry, under the appli- 
cation of the stethoscope ; and when they do not thus foil the stethoscopist, 
the laryngeal sounds frequently obscure the pulmonary, both bronchial and 
vesicular. In the case of pneumonia, however, percussion may give us 
valuable aid. In both complications, the sputa should be examined, when 
the appearances characteristic of those inflammations may sometimes be 
observed ; and, in reference to bronchitis, the copiousness of the expectora- 
tion, apart from any intermingled strise of blood, will suggest secretion 
from a more extended surface than that of the larynx and trachea. When 
the bronchial membrane is thus implicated, if the stethoscope be applied to 

. the chest while the child is in the act of coughing, the presence of an 
abnormal quantity of mucus will, in general, be quite manifest. 

Nothing in the pathology of croup has attracted so much attention, as 
the imperfect false membrane thrown out on the free surfaces of the larynx 
and trachea, more especially the latter, whence the name cynanche trachea- 
lis. Dr. Stokes, building on a remark of Dr. Graves, that reproduction is 
almost limited to the white tissues, refers to the activity of that function in 
childhood, and suggests that the product of fibrinous exudation, is one of 
these; and Dr. Williams suggests that the inflammation dips into the sub- 
jacent cellular tissue, whence the exudation of coagulating lymph escapes 
through the membrane by exosmosis. But if this were the case, I can see 
no adequate reason why the same fibrinous exudation should not appear in 
every mucous inflammation. Without, however, raising objections to the 
conjectures of these eminent physicians, and even admitting the truthful- 
ness of both, for they are not incompatible, I may indulge in^ two or three 
others. First, the tubes which perform the simplest function, that of mere 
transmission, have the least complication of structure, secrete the least 
mucus, and throw off the smallest amount of epithelial cells. The trachea is 
one of these, when we compare it either with the larynx above or the bronchi 
below ; which (especially the latter) secrete much more than the interven- 
ing tube. Now, this mucous secretion, may not only diminish the fibrinous, 
but with the deeper stratum of epithelium prevent its adhesion to the sur- 
face which pours it out, and by dilution keep its molecules from uniting 
into a floating membrane j while the more limited secretion and epithelial 
exfoliation of the trachea may not offer the same obstacles. Second. In 
childhood the tissues are less distinct from each other, in organization and 
properties, than they become in manhood. Thus the differences between 
arterial and venous blood, fibrous membrane and cartilage, mucus and serum, 
muscle and any other fibrous tissue, become more defined and striking, with 
the progress of life. With these facts before us, we may conjecture that 
the lining membrane of the trachea approaches nearer to the character of a 
serous membrane in children than in adults ; and when inflamed is there- 



INTERIOR VALLEY OF NORTH AMERICA. 823 

fore more likely to afford a fibrinous exudation. Third. In the absence 
of an exact comparative analysis of the blood in the two stages of life, we 
may presume, that during the period of growth, that element which is to 
contribute most to the building up of the organs, will be abundant, and 
therefore, in inflammation of the trachea the hyperinosis of the blood may 
be such as greatly to facilitate the exudation of fibrine. Hence we may 
perhaps understand why in certain cases of croup imperfect false membrane 
overspreads the pharynx, extending even into the mouth ; and why, it is 
that in the coryza of infants, fibrinous exudation is sometimes mingled with 
the mucus of the nasal passages. 

In the progress of croup the partially detached or floating fragments of 
membrane as formed in the larynx or trachea become a great cause of 
danger. But we must also take into view the thickening from congestion 
of the lips of the glottis, the subjacent serous infiltration, although it may 
not amount to manifest oedema, and the adherent mucus at the rima glot- 
tidis. Still farther we must remember, what slight irritations in childhood 
are sufficient to excite the muscles into spasmodic contraction ; and how 
much of that dyspnoea, often paroxysmal, attendant on croup, may be attri- 
buted to abnormal contraction of the little muscles which move the aryte- 
noid cartilages. Dr. Stokes has referred to this complication of spasm with 
inflammation, in a manner so pointed, as to indicate that it was doubted by 
many. In this country, however, it has at all times been recognized, and 
made the basis of a part of the treatment of that disease. 

II. Method of Cure. — In the forming or catarrhal stage of croup, before 
the development of fever or the change of simple congestion into inflamma- 
tory, a tepid bath and an emetic will often put an end to the disease, by per- 
spiration and a free secretion of mucus. When by slow ingravescence or a 
sudden invasion the disease has taken on the character of a phlegmasia, an 
active treatment is imperatively demanded. In the beginning of this stage, 
the physician often finds on his arrival that the child has been immersed in 
a warm or hot bath, and then wrapped up in blankets, whereby the fever 
and of course the inflammation have been greatly aggravated. No perspira- 
tion can follow this hot regimen, and the physician should never give it his 
sanction. The treatment in this stage of this disease should be antiphlo- 
gistic, and whenever the fever is well developed, the first remedy is blood- 
letting. In children of a year old the application of two, three or four 
leeches to the larynx and trachea down to the sternum will be sufficient. In 
want of these, scarification and small cups may be applied to the nucha and 
the region of the larynx. If this be not practicable, venesection should be 
attempted, and from one to two ounces of blood drawn. At a more ad- 
vanced stage that mode of depletion is preferable to the others, and without 
reference to quantity, the flow of blood should be continued till perspiration 
of the face, yawning, or nausea indicates the approach of syncope, beyond 
which it should never be carried. SucJi a bleeding ought never to be 



824 THE PRINCIPAL DISEASES OP THE 

repeated, and we should seldom resort to the lancet a second time unless 
there be a conjoined bronchitis or pneumonia. Leeching or cupping may, 
however, be employed when a repetition of the phlebotomy would not be 
proper. Immediately after the bleeding the child may be immersed in a 
tepid bath, where it should remain from fifteen to thirty minutes, — a much 
longer time than is usually thought necessary. Instead of lying buried up 
in the water, it should stand or sit in the tub, and have the water poured 
over its body by two or three assistants working at the same time. This 
method is much more soothing and sedative than immersion. It reduces 
the fever, predisposes the mucous membrane and skin to increased secretion, 
allays the irritated state of the nervous system, and quiets the spasmodic 
action of the muscles of the glottis, whereby the dyspnoea is diminished. 
While this is going on an emetic should be given. Of any medicine tar- 
tarized antimony is the best, and most easily administered. Full vomiting 
should be effected, and after the operation the little patient may be mode- 
rately covered, and, provided the room be not too hot, allowed to rest. In 
many cases convalescence now begins, and advances with free catarrhal secre- 
tion. Sometimes, however, the child remains anxious and restless, with 
dyspnoea, when a potion of laudanum and calomel should be administered, 
under the action of which his nervous irritability will be allayed, while the 
calomel, by its action on the liver and bowels, will produce or prepare the 
way for those alvine evacuations which will carry off the existing contents 
of the digestive canal, and make salutary revulsion from the inflamed organ. 
If this simple but energetic treatment should not arrest the disease, the 
fever will soon begin to rise, and its intensity will show the violence of the 
inflammation. Without recurring to what has been said on the repetition 
of bloodletting, I may now insist, with the best authorities, that the con- 
tinued administration of tartarized antimony and calomel is our great 
resource. The former may be given in nauseating doses even to occasional 
vomiting ; and the latter in one, two or three grain doses, according to the 
age of the child, every two hours; and both must be continued till the fever 
abates, or the signs of exhaustion or carbonization of the blood appear. A 
good vehicle for the tartar, is a syrup of polygala senega, the modus ope- 
randi of which was first pointed out by Dr. Archer. If the child have great 
restlessness, tepid bathing may be again employed, and small doses of lauda- 
num or paregoric be administered. If the medicines should not act on the 
bowels, a gummy, oleo-saccharum should be administered, which in the 
mucous inflammations of children generally has a soothing and happy effect. 
If the bowels should be too active, and especially if they should throw off 
watery discharges, laudanum should be given. Blisters have been both 
commended and condemned. I have certainly seen them useful. They 
should be applied over the lower cervical vertebrae, or over the trachea 
below the larynx. They should be removed as soon as vesication begins, 
and the surface covered with an emollient poultice. 



INTERIOR VALLEY OF NORTH AMERICA. 825 

In more advanced stages but little can be done. The spasmodic action of 
the glottis may be moderated by an emulsion of assafoetida with laudanum ) 
and to promote the expectoration of the false membrane, a strong infusion 
of the senega root may be administered. The dyspnoea still continuing, 
with a haggard expression, and the appearance of a smoky hue of the lips, 
the question of tracheotomy comes up. The point then to be decided is, 
whether bronchitis or pneumonia has disorganized the lungs, and thus con- 
tributed to the asphyxia which is now going on. If they have not, there is 
no objection to the operation; but I confess that in this country I have no 
great reliance upon it as a resource in such an emergency, seeing that parents 
generally oppose it, and that the greater number of our physicians are not 
fully prepared for its performance under the difficult circumstances which 
then exist. 

Croup is a relapsing disease, and the danger, always great, is largely from 
spasm. The chief causes of relapse are, first, premature exposure to cold and 
moisture, or, in any mode, getting the skin chilled ; second, an inordinate 
meal, especially of animal food. I once saw a child pass through a severe 
attack of croup, recover so far as to run about, and sit at the table with its 
parents, who allowed it to eat a hearty dinner of meat. In a few hours the 
disease was reproduced, and in as many more it proved fatal. 

Many children are subject to croup, but they are also subject to catarrh, 
and not a few of their attacks are of the latter kind only. A diet which 
excludes meat, is proper in such cases. The cold bath and spending much 
time in the open air are likewise beneficial. But change of locality from a 
humid to a drier atmosphere, or from a colder to a warmer climate, may be 
requisite. 

III. Secondary Croup. — This laryngotracheal inflammation, like the 
laryngitis of adults, is often secondary. Thus that form of pharyngitis 
which has been called diphtherite by Bretonneau, often descends into the 
larynx and trachea ; the same is occasionally true of thrush, and of ery- 
sipelas, but and above all of the eruptive fevers. Dr. Stokes has drawn a 
parallel between the symptoms of primary and secondary croup, in which 
the most important point is, that the fever accompanying the latter is of a 
typhous character. This may be correct, as the diseases which are its patho- 
logical causes do not possess a high and pure phlogistic character ; and as it 
supervenes on their more advanced stages, bloodletting is then not proper. 
With the exception of this remedy, and in some cases the substitution of 
ipecac, or lobelia inflata for tartar emetic, the treatment of secondary must 
be the same as that of primary croup. 



CHAPTER XIII. 

LARYNGISMUS STRIDULUS.— PERTUSSIS.— ASTHMA.— HAY-ASTHMA. 

We have in this chapter a group of maladies which can scarcely claim ad- 
mission among the phlegmasiae, yet there would be perhaps still less propriety 



826 THE PRINCIPAL DISEASES OF THE 

in placing them with the neuroses. However diverse in their phenomena, 
there are pathological elements common to the whole, which bear great 
affinity to those of the inflammations we have been studying. These ele- 
ments are catarrhal or passive congestion of some portion of the respiratory 
mucous membrane, increased mucous or sero-mucous secretion, and spasm 
of some of the muscles of the organs of respiration. They agree still 
further in this, that while inflammation is not essential to either, each now 
and then presents it ; finally they concur in presenting a paroxysmal cha- 
racter. Here the common characteristics terminate, and the special differ 
widely. Thus the first is an occasional short paroxysm, the second pro- 
tracted by paroxysms, and not repeated after they finally cease ; the third 
endures for years in irregularly recurring attacks, and the fourth has an 
annual return. The first two, moreover, are chiefly met with in childhood, 
the last two belong to adult age. 



SECTION I. 

LARYNGISMUS STRIDULUS, SPASMODIC CROUP, OR CHILD-CROWING. 

I. History. — The symptomatic history of this complaint seems to justify 
its being placed near the last ; in many cases, however, it seems to be a 
mere neurosis, though in others, it is associated with catarrhal symptoms. 
Cold is indeed one of its causes, while another is gastric repletion ; another, 
less common, perhaps, the irritation of teething. In one instance I knew it 
prove fatal to a child which had from birth emitted some abnormal sound from 
the larynx, the cause of which was not understood. Although generally a 
disease of early childhood, it is not confined to that period ; for, to say 
nothing of European observations, Dr. Dickson, of Charleston, has seen a 
person above fifty years of age, who was subject to it j* and I knew a lady 
above thirty who has had several attacks, always brought on by exposure. 

The great (negative) characteristic of spasmodic croup is the absence of 
fever, though the pulse, as in other diseases of nervous irritation, is some- 
times accelerated and variable. The skin, however, is neither hot nor dry, 
nor does a white fur appear upon the tongue. The suddenness of the attack 
and the intervals of free breathing are diagnostic symptoms of a positive 
kind. When catarrhal symptoms are present, the absence of fever, and the 
disproportionate violence of the dyspnoea, will still distinguish it from true 
croup. But the most pathognomonic symptom is the peculiar quick, loud, 
crowing sound produced by the passage of the air into the larynx through 
the straightened glottis, attended with violent convulsive and struggling 
action of the muscles generally, except those of the hands and feet, which 
are in a more fixed condition, for the flexors are either in rigid contraction 
or the extensors paralyzed, as appears from the turning in of the thumbs and 

* Manual of Pathology and Practice, p. 165. 



INTERIOR VALLEY OF NORTH AMERICA. 827 

fingers, and the flexion of the feet and toes. The spasm of the glottis may 
be such as to produce almost immediate suffocation; but more frequently it 
is prolonged with such diminution of the chink as to generate a bluish tint 
by slow asphyxia. 

In the absence of any ascertained uniform pathological cause for the 
spasm of the muscles of the glottis in this malady, a variety of suggestions 
has been made : first, that it depends on cerebral irritation, which is in 
fact but a hypothesis; second, that it results from the pressure of enlarged 
lymphatic ganglia on the pneumogastric nerves, or their recurrent branches, 
but a disease so paroxysmal could scarcely result from a cause so constant ; 
third, that it arises from the pressure of an enlarged thymus gland. The 
same remark will apply to this. I have met with but one case of that en- 
largement. It was found in a boy nine years old, who died of purpura 
hemorrhagica. He had not suffered from this disease ; fourth, that it is 
excited by dentition ; but it often occurs before that function has com- 
menced. It seems probable that many cases of this malady, in early in- 
fancy, are in our classifications mixed up with those forms of abnormal re- 
spiration and circulation, which are known under the name of morbus 
ceruleus. 

As bearing on the whole subject we should recollect how easily the mus- 
cles of children are thrown into spasm, that their convulsions seldom in- 
volve all the muscles of animal life, that they oftener affect those of the 
face and throat than any others, and that spasmodic croup may perhaps be 
but an example of infantile and puerile convulsions, limited to the muscles 
of the larynx and pharynx, and produced by various local irritations. 

II. Treatment. — I shall not dwell on the treatment of this malady. A 
towel dipped in cold water and wrapped round the throat, is one of the best 
and promptest means of relief; the lady, whose case I have mentioned, 
has often been promptly relieved by it. Professor Meigs has informed me, 
that he once found a young man lying in the street, in Philadelphia, nearly 
asphyxiated from this malady, who was instantly relieved by the same ap- 
plication. Children, its chief subjects, when no catarrhal symptoms are 
present, may be plunged into cold water, or have it thrown upon them. 
With the coexistence of catarrhal symptoms, they should be immersed in a 
tepid bath, and have the cold applications to the throat only. In connec- 
tion with these measures, tartar emetic, or ipecac, or the wine of either of 
those medicines, should be administered with laudanum, to the extent of 
vomiting and incipient narcotism. No other antispasmodic has greater 
power ; and as an indigestible meal is often the exciting cause, the vomiting 
may prove highly beneficial. Other antispasmodics, as assafoetida, may be 
useful; and it is in cases of this kind that Dr. Godman found the Scotch- 
snuff plaster to the tracheal region so beneficial. When the child is in 
the period of dentition, it will be proper to lance the gums, although there 
may be no evidence of their being in fault. 



828 THE PRINCIPAL DISEASES OF THE 

SECTION II. 

PERTUSSIS OR HOOPING-COUGH. 

I. History. — I shall give no description of this well-known and strongly 
characterized disease. Although introduced here among the simple phleg- 
masia^ it is not, as I have already said, one of them ; for even admitting 
the existence of inflammation as an essential pathological element, which 
has been denied, the remote cause is evidently a specific aeriform poison. 
This by some is believed to be of local or atmospheric origin, as is that of 
influenza ; by a greater number, to be of animal origin, that is, a contagion. 
I cannot settle this controversy, but will confine myself to the mention of 
the following observations. Several years since, a man and his wife from 
the interior of the State of Indiana, called on me with a child which labored 
under ophthalmia. They immediately passed up the river, more than one 
hundred miles, to visit a family in the country. When they arrived, they 
found the children of the family affected with hooping-cough. After re* 
maining about three weeks they returned, and called on me again, when I 
found that the child had that disease fully developed. Professor Short gave 
me the following item. There was no pertussis in his neighborhood, when 
a mechanic, affected with this disease, was employed by him to do some 
work within his dwelling. Not long after the work was begun, one of his 
children, who had never had it, was attacked and died. It would be easy 
to multiply well-observed facts of this kind, and they seem to indicate con- 
tagious propagation ; yet it is possible that the child might only have been 
in these cases exposed to a local atmosphere which contained a poison, not 
secreted by morbid action. This malady is perhaps always prevailing in 
some part of our Valley, and is by all the people regarded as contagious. 
The fact of its generally occurring but once, places it with some of the most 
certainly contagious exanthems, but when I recollect that yellow fever in 
general attacks but once, this fact loses some of its value. As to second 
attacks, they are rare, for at this moment I recollect but a single well- 
authenticated example. A gentleman who had in infancy come near dying 
with hooping-cough, experienced a second strongly marked and tedious 
attack when he was nearly twenty-two years of age, in the summer of 1807, 
the disease being at that time epidemic; and again, when he was sixty years 
old, in the winter of 1847-8, he had an attack, the malady being then 
common, which had all the symptoms, except the hooping. Of course it 
cannot be affirmed that this iocis pertussis. It was worthy of remark that 
between his first and second attacks he had often been in close association 
with those who labored under the disease. I have never seen a sporadic 
case of hooping-cough, nor, on the other hand, known it to prevail as a 
wide-spreading epidemic. After sojourning for a while in one neighborhood 
it enters and prevails in like manner in another. 



INTERIOR VALLEY OF NORTH AMERICA. 829 

II. Pertussis is indefinitely self-limited. Many years since it was 
affirmed that artificial musk would cut it short, but I never saw more than 
palliation result from it. Afterwards, vaccination in the latter stages of 
the disease was said to arrest it, but in my own practice it has failed to do 
so. The prussic acid has been recommended as curative, but Professor 
Short informs me that on a full and fair trial it did not exercise that power. 

Infants may die asphyxiated by this disease from the combined influence 
of profuse sero-mucous secretion and spasm of the glottis, and the danger 
is increased by bungling attempts to wipe the tenacious mucus from the 
mouth, in the latter stage of a fit of coughing, at the moment when after 
repeated expirations, the air is about to be drawn into the lungs. But a 
more frequent cause of death is a supervening croup, bronchitis, or pneu- 
monia, generally excited by exposure or a sudden change of weather. In 
all severe cases, whenever a considerable degree of fever co-exists in any 
stage, a pulmonary complication should be suspected, especially if the Tittle 
patient have cough of a common kind between the paroxysms of the specific 
disease, and during those intermissions the lungs should be carefully ex- 
amined by auscultation and percussion. Another source of danger and 
death is cerebral, and appears to result in part from the concussion of the 
brain by the violent coughing, and in part from an interruption to the 
passage of the blood from the right to the left side of the heart, whereby it 
is dammed up in the sinuses of the brain. Under these pathological condi- 
tions, cerebral inflammation, either simple or tubercular, may be awakened ; 
but the venous congestion thus produced favors serous effusion into the 
ventricles. The -same effusion has sometimes been observed externally 
about the face and neck, and was doubtless produced in the same way. 
The stomach suffers seriously in this disease. So essentially seated in the 
superior and inferior or recurrent branches of the pneumogastric nerves, 
which largely supply the stomach, that organ, always ready to suffer with 
others, can scarcely fail to sympathize with the larynx; but there is an- 
other cause for its disordered condition. Much the larger portion of the 
mucus which should be expectorated is swallowed, and being (as I am con- 
vinced) of very difficult digestion, accumulates in the organ, which it irri- 
tates into the secretion of acid, often quite obvious when vomiting takes 
place. This secondary condition of the stomach, as so often happens in 
pathological conditions, immediately reacts on the suffering larynx, and 
aggravates the original disease. Although pertussis cannot with any cer- 
tainty be shortened, it may be prolonged ; and when it occurs in autumn, 
the cold and variable weather is apt to render it protracted. The same 
cause may even produce relapses, that is, generate catarrhal symptoms with 
a hooping cough, several months after the disease commenced. When no 
accidental inflammation supervenes, the latter stages of this malady seem to 
be those of a mere nervous affection ; very slight irritations or mental emo- 
tions being sufficient to bring on a convulsive paroxysm of cough. Its 



830 THE PRINCIPAL DISEASES OF THE 

relapsing tendency and the treatment it demands in the advanced stages 
also mark it as a neurosis. 

Hooping-cough of itself can scarcely be regarded as a fatal disease, and as 
yet no specific and constant anatomical lesion has been assigned to it. The 
morbid appearances after death in the early stages are generally those of 
laryngitis, bronchitis, or pneumonia ; at a later period these are often 
replaced by the lesions of hydrocephalus, and still later, ulcers of the larynx 
and dilatations of the bronchial tubes, or emphysema of the lungs have been 
found. Hasse, who erroneously regards it as bad catarrh in persons prone 
to strong nervous reaction, says that no lesion of the pneumogastric nerves 
or solar plexus has been met with. 

III. Management and Medicines.* — No one can doubt the necessity 
in this malady of a vigilant attention to the rise of the laryngitis, tracheitis, 
bronchitis, pneumonia and hydrocephalus, of which I have spoken, which 
should respectively receive their appropriate treatment, not to be set forth 
under this head. These, in fact, are so many distinct phlegmasiae, of which 
pertussis is the pathological cause. When none of them springs up, the 
malady will only demand palliatives. 

In and of itself pertussis presents us with simulative catarrhal congestion 
and secretion, in the mucous membrane of the respiratory tubes. Cold is 
not its producing, but may be its exciting cause, as it may excite influenza, 
when that specific disease is prevalent, in persons who might otherwise escape ; 
or saline purgatives may lead to cholera, when that peculiar malady reigns. 
Yet the catarrh of pertussis cannot be arrested like that from atmospheric 
changes ; but while this is true, it is equally true that it- may be mitigated. 
In the beginning, if the child have a full habit, and is decidedly feverish, 
if there be fears of suffocation in the paroxysms of cough, or signs of great 
disturbance in the circulation of the head and brain, it will be proper to 
bleed freely once from the arm, not so much to subdue inflammation as to 

* In Dr. Condie's excellent and comprehensive Practical Treatise on the Diseases of Children, we have 
a catalogue of about fifty articles of the materia medica which have been strongly recommended or 
condemned by more tban sixty eminent writers of Europe and America. The materia curandi of 
phthisis, cancer, or hydrophobia, if collected with equal industry, would, I suppose, be still more exten- 
sive; yet those diseases continue to run their course to a fatal termination. The really curative treat- 
ment of any disease demands but a very limited number of articles ; and the efficiency of a catalogue 
is often inversely with its length. As it grows, every new article makes a declaration against the ineffi- 
cacy of its predecessors. In a disease that is self-limited, with a tendency to terminate in health, yet 
of no definite duration, there is the greatest possible opportunity for being entrapped into an erroneous 
estimate of the effects of what we may employ. I have observed that hooping cough is less fatal among 
our scattered country population, where children run at large, and take but little medicine, than in 
our large cities where the reverse is the case. Yet these people have their simples and also their 
charms, to which they ascribe the favorable issue of the disease, forgetting that without them the result 
would probably have been the same. In the year 1811, when travelling on horseback with a medical 
friend in a newly settled part of Ohio, an Irish woman standing in the door of a cabin in the woods, 
called to him, and inquired what would cure her child of hooping cough ? As we rode on I remarked on 
the singular coincidence of her happening to address a physician, when he told me that she saw he was 
riding a horse with four white feet, and that in some parts of the country it was believed that what a 
traveller, thus mounted, might recommend, would cure that disease. Whatever simple he might have 
advised, would, if the child recovered, be regarded by this woman as having made the cure. 



INTERIOR VALLEY OF NORTH AMERICA. 831 

lessen the volume of blood, which must of necessity pass through the lungs. 
The medicines which may be required, will, moreover, act more kindly after 
such a bleeding. But a repetition will never be required unless some 
inflammatory complication should spring up; and may do harm by increas- 
ing that morbid sensibility, which often gives us so much trouble after the 
catarrhal symptoms have nearly died away. A more important palliative, 
though comparatively inefficient if a required bloodletting have been preter- 
mitted, is an emetic. For a young child nothing is more safe and conve- 
nient than the wine of ipecacuanha. Older ones may take the powder, 
which may be advantageously combined with calomel so as to make a sub- 
sequent impression on the liver and bowels. Tartarized antimony is not 
objectionable, and if inflammation should be suspected, should be preferred 
to ipecacuanha, as more antiphlogistic. It may be given in solution, or in 
the form of vinum antimonialis, and consulting the prepossessions of parents 
when the child is very young, the latter should be preferred.* Other emetic 
medicines, as the squill and lobelia inflata, may be employed, but their 
effects are less certain, and their management more difficult. As nauseating 
expectorants they may perhaps be preferable to the medicines just men- 
tioned ; and of the two the lobelia should be preferred, as possessing a slight 
narcotic and antispasmodic property, in connection with its emetic power. 
I am not however an advocate for the constant exhibition of nauseating 
doses of any kind of medicine in this malady, except when manifest mucous 
inflammation exists, but greatly prefer the frequent repetition of vomits, 
care being taken that they do not produce watery diarrhoea. For reasons 
connected with the use of opium, the best times to give them are early in 
the evening and early in the morning. Immediately after the former opera- 
tion the child should be composed with an appropriate dose of some prepara- 
tion of opium, to which, every second or third night, two, three, or four 
grains of calomel should be added. When it is intended to exhibit an 
emetic in the morning, an opiate of sufficient strength to produce sound 
sleep should be given at night. This alternation of vomiting and slight 
narcotism greatly increases the efficacy of both ; and keeps down that mor- 
bid irritability of the respiratory organs which constitutes so troublesome an 
element in this disease. 

Intimately associated, as are the stomach and larynx by the pneumogas- 
tric nerves, we can understand why the condition into which the former is 
brought by an emetic may affect the latter. Vomiting is in fact an anti- 
spasmodic to the muscles of the glottis ; and it no less certainly contributes 
to the dislodgment of mucus from the aerial passages. But its benefits are 
not limited to these effects. It rids the stomach of the acidulated mucus 

* I am by no means convinced that the watery and the vinous solutions of tartarized antimony are 
quite identical, in the impression they make on the system. The latter, it has appeared to me, is 
milder, less irritating, and less depressing. When we consider the complex character of wine, we cannot, 
I think, but admit the possibility of isomeric or other changes in that medicine, which may modify its 
action. 



832 THE PRINCIPAL DISEASES OP THE 

of which I have spoken, and by improving its condition prevents its sinister 
reaction on the larynx. As a means of neutralizing this acid, the carbonate 
of potash or soda may be regularly administered between the times of giving 
the emetic; and constitutes, perhaps, one of the best palliatives in this 
malady. I will not insist on the value of combining it with cochineal, but, 
in general, parents give the colored compound with more faith and willing- 
ness, than the transparent solution.* Other medicines may, however, be 
united; as, for example, it may be dissolved in a weak infusion of lobelia, 
or assafoetida, and also made the vehicle of laudanum or paregoric, the tinc- 
ture of hyoscyamus, or a solution of belladonna, according to the judgment 
formed in each case. These various articles, of which I prefer assafcetida 
and opium, allay > spasm, and fulfil one of the most important indications of 
the palliative treatment. The longer the disease has continued, no contingent 
inflammation being present, the greater is the necessity for antispasmodics 
and subnarcotics ; but throughout the whole course, they may be adminis- 
tered with advantage. Sulphur was once regarded as antispasmodic or ner- 
vine, and subsequently as acting somewhat specifically on the mucous mem- 
branes of the lungs and larynx. Both views suggest its adaptation to 
hooping-cough, and Dr. Condie speaks highly of the palliative effect of the 
following formula : — 

R. — Ipecac, ..... grs. iii.-iv. 
Precipitated Sulphur, . . . gss-^j. 

Extract of Hyoscyamus, . . . grs. iv.-xii. 

Mix and divide into twelve powders. One to be repeated every three or four 
hours. 

Among our popular remedies garlic has always had considerable rank. 
Now, this bulb, in addition to an acrid oil, contains sulphur, on which, per- 
haps, a part of its efficacy depends. It is given, internally, as a syrup, and 
also is applied externally. In the latter case it is stewed in lard and rubbed 
over the cervical and dorsal spine. I have no doubt of its palliating in- 
fluence. 

In advanced stages of the disease, chalybeates and bitters have been found 
beneficial. When the child inhabits a malarial region, the bark or sulphate 
of quinine is often of great value. 

Children are often injured in hooping-cough by indulgences in diet, which 
do not so much bring on or promote inflammation as injure the stomach, 
and increase its sinister reactions on the parts which are the seats of the 
malady. In the early stages the diet should be sparing and simple ; in the 
advanced more restorative. They are also frequently injured in our towns 
and cities by being confined in heated rooms. When the weather is not 

* Dr. Pereira, in his admirable Elements of Materia Medica, after showing, on the authority of the 
organic chemistry, the complex constitution of cochineal, and that it contains peculiar principles, de- 
clares that there is not the least evidence of the diuretic, diaphoretic, antispasmodic, or anodyne qualities 
of this substance. But the existing absence of any evidence does not prove it inert. 



INTERIOR VALLEY OF NORTH AMERICA. 833 

bleak or rainy they should be taken daily into the open air from the com- 
mencement. In the tedious declining stage, such exposure, with travel and 
change of locality, are often indispensable. If a chronic bronchitis should 
now exist, a southern climate for winter will be advisable, but otherwise it 
need not be sought, as cool or cold air is one of the best means of finally 
subduing the irritability of the nervous system. It is, however, by its 
action on the respiratory passages and not on the skin that it does good, 
and therefore the latter should be well protected. Among the remedies for 
this stage, however, the cold dash is one of the most valuable, care being 
taken to secure immediate reaction. 



SECTION III. 

ASTHMA. 

I. Dyspnoea, phthisic, or difficult breathing,'may result from various ana- 
tomical derangements of the thoracic organs, such as aneurisms of the great 
arteries, swelling of the thymus gland and enlargements of the lymphatic 
ganglia of the posterior mediastinum. Much oftener do hypertrophies both 
concentric or excentric, of the heart, give the same result, especially when 
aided by slight auxiliary causes, such as a wrong posture, a full meal, 
ascending a staircase, or a gust of passion, which operate apparently by in- 
creasing the irregular action of the respiratory apparatus. Empyema, 
hydrothorax, pneumo-thorax, bronchial dilatation, hepatization, emphysema, 
oedema, and vesicular dilatation, are causes of habitual dyspnoea, which is 
liable to aggravation in paroxysmal violence, by whatever can hurry the 
circulation or respiration, interfere with the passage of air through the 
bronchi, or disturb the innervation. The whole of these cases of difficult 
and anxious pulmonary respiration have in past times, by mere symptomat- 
ists, been classed together ) and, without regard to the anatomical lesions 
of which they are but the expression, ranged under one head — asthma con- 
tinued or periodical. To this artificial grouping succeeded the analysis 
(constituting one of the greatest triumphs of pathological anatomy), which 
has disclosed to us that dyspnoea may depend on lesions of structure ex- 
ceedingly variant from each other. One of these has been fixed upon as 
the proximate cause of that form of disordered respiration, which is gene- 
rally denominated spasmodic asthma — dry and humoral. I refer to perma- 
nent vesicular dilatation of the air-cells of one or many of the pulmonary 
lobules. But to this hypothesis there are several objections. First. That 
lesion is constant, but the true asthmatic dyspnoea is essentially periodical, 
and sometimes presents weeks or months of perfect exemption. Second. 
It has never been shown, nor does it appear lioio such dilatation can gene- 
rate the striking phenomena of a fit of asthma. ' Third. It has frequently 
happened that after the death of asthmatic patients, no vesicular dilatation 

voi. ii. 53 



834 THE PRINCIPAL DISEASES OF THE 

has been found. Yet it has often existed, but in the absence of all exact 
knowledge as to the mode of its production, we are as free to say that it 
was occasioned by the asthma, as that it had caused that disease. That any 
organic lesion within the thorax may so disturb the innervation of the 
lungs and respiratory muscles as to generate asthmatic breathing cannot be 
denied, and that such breathing may at length generate anatomical lesions 
is exceedingly probable ; but the question is, whether the kind of respiration 
requires for its existence a previous lesion of organization. My answer must 
be in the negative, and in the present state of my knowledge, derived from 
both reading and observation, I am compelled to admit a form of dyspnoea, 
idiopathic, and of course not dependent on anatomical lesions, to which the 
term asthma may be applied. When eliminated from all other dyspnoeas, 
its symptoms are as distinctive, and its general history is as peculiar as that 
of most other functional diseases. 

II. History and Causes. — Of our sporadic diseases, asthma, the diag- 
nostic symptoms of which will be given presently, is by no means one of 
the most uncommon. I am unable to give its relative frequency in our 
higher and lower latitudes. My own observations have been chiefly made 
in the middle. It affects both sexes. Occasionally it extends to several 
members of a family, yet it is by no means as transmissible as phthisis. 
With that malady, as has been observed elsewhere, it seems to have a rela- 
tion of antagonism or displacement. Thus, I do not recollect to have seen 
a tubercular patient afflicted with asthma, nor an asthmatic become tuber- 
cular. Again, the predisposed to phthisis even after symptoms of incipient 
tuberculization have appeared, sometimes become asthmatic, and then the 
tendency to consumption is at an end. In families, we occasionally see one 
member consumptive, another asthmatic. I know a medical gentleman 
who a few years since thought himself threatened with tubercle ; but at 
length his strength and flesh increased, and very lately, when forty-six 
years old, he has had several well-marked nocturnal paroxysms of asthma. 
He has lost a daughter, with spontaneously developed tuberculization of 
the lungs, as ascertained by post-mortem inspection ; and his mother, now 
eighty-five years of age, has for most of her life labored under asthma. In 
reference to his daughter's disease, it is proper to say that his wife is free 
from any tubercular taint. I know another gentleman, whose form would 
presage consumption, but who has been asthmatic for many years, that 
lately lost a daughter from phthisis soon after the birth of her first child. 
.Another still, with a very different form, was subject to violent attacks of 
asthma for several years, lost a daughter with phthisis, her mother having 
no apparent tendency to that malady. Leaving it with others to speculate 
on these relations between consumption and asthma, I may say that he who 
is predisposed to or threatened with the former may feel gratified at the 
•development of the latter. I have seen many cases of asthma, which ap- 
peared to arise independently of all family predisposition. A case in point 



INTERIOR VALLEY OP NORTH AMERICA. 835 

occurs to me at this moment. A man and his wife, each of robust frame, 
had six or seven children of vigorous constitutions, and one who was seized 
with asthma — which became permanent while he was yet a young man. 
In general, asthmatics are not very tall, and have broad chests, with some 
tendency to fleshiness, if not obesity. Children are more or less subject to 
this disease, but I suspect that some of these cases are but examples of 
dyspnoea from congenital formation, or pulmonary lesion following on per- 
tussis. It is in early manhood about the time that phthisis oftenest occurs, 
that I have most frequently seen asthma begin. This is the dyspeptic 
period, and the first paroxysms have almost invariably been preceded by an 
aggravation of that malady. When the dyspeptic era passes away before 
the fortieth year, or much earlier if the condition of the stomach should 
improve, the asthma in some cases ceases, but in others it continues through 
life, which on the whole it does not seem to shorten. The later in life it 
sets in, the greater is the probability that it has for its predisposing or ex- 
citing cause some organic affection. 

Of external and material causes, I can say but little, unless we suppose 
that agents which reproduce the paroxysms may have been the original or 
producing causes, which would perhaps often be erroneous. The inhalation 
of certain atmospheric impurities will excite the disease in the predisposed. 
The sinister influence of powdered ipecac, in certain idiosyncrasies is well 
known.* 

I have not been able to discover that those who work in atmospheres 
impregnated with mechanical impurities, are particularly liable to this dis- 
ease, though for a while after entering them they have a considerable degree 
of dyspnoea. At our salt-works, in our collieries, and in cities where great 
quantities of coal are consumed, I have been unable to discover any 
uncommon prevalence of this malady. Of these cities, Pittsburg is the 
most remarkable, and Dr. Addison informs me that he had seen many cases 
of the disease originated there ; yet Dr. Spear and Dr. Denny stated that 
they had known many patients signally relieved of it by removing from 
the country into the city. This, also, I have known in Cincinnati; and 
the relief was generally greatest when they went into the lowest and least 
ventilated places. On the other hand, however, the change has sometimes 
greatly aggravated the disease ; and relief has come from seeking a high, 
dry, and windy locality. In some asthmatics, an impending snow-storm 
will bring on a paroxysm ) in others, the return of a particular season pro- 
duces the same effect. On the whole, atmospheric influences, appear to be 
exciting if not producing causes ; but their effects are by no means the 
same in different patients, but often, as we have seen, the very opposite. 

* Dr. Richard Allison, Surgeon in Chief of St. Clair's and Wayne's armies, and one of the earliest 
physicians of Cincinnati, was slightly asthmatic, and could not eyen weigh out a dose of ipecac, with- 
out haying a severe paroxysm. Other atmospheric impurities did not have the same effect. Can we 
admit any connection hetween this ohservation and the results of empoisoning by emetics, taken into 
the stomach or injected into a vein ? According to Majendie, the lungs were engorged and inflamed 
in such experiments. 



836 THE PRINCIPAL DISEASES OF THE 

III. Symptoms and Pathology. — The prominent and most character- 
istic symptom is a laborious and difficult respiration, in general coming on 
suddenly, and prompting the patient to rise from a recumbent posture. It 
seems evidently to be pulmonary, not laryngeal. The muscles of respiration 
contract in a convulsive, but somewhat disassociated manner, and the patient 
has a feeling of thoracic constriction, as if the proper expansion did not 
take place. A wheezing sound can be heard on approaching the patient, 
and when the ear or stethoscope is applied, if expectoration have not com- 
menced, dry, sibilant, or chirping sounds are heard generally over the chest, 
which often cease while the auscultation is still continued. If expectoration 
have begun, the bird-like notes are largely replaced by mucous rales. In 
some patients the dry stage is so prolonged and the expectoration so incon- 
siderable, that the disease has received the name of dry, nervous, or spas- 
modic asthma; in others, on the contrary, the expectoration is copious 
from the beginning, and the malady is then called humoral asthma. More 
or less wandering pain, with a sense of fatigue, occurs in the muscles of 
respiration. The pulse is natural, or hurried and variable, but rarely 
febrile, and there is seldom any increased heat — oftener, indeed, a reduction, 
with a pallid or dusky hue of the face. Very commonly, the stomach at 
the same time shows a fit of dyspepsia. In the early stages, the attacks 
are less violent, and occur but seldom, and then generally under the influ- 
ence of some exciting cause, which seems to be a paroxysm of dyspepsia. 
I say seems, because it is possible that the pulmonary and gastric affections 
may have the same parentage. An attack may continue for a few hours 
only, or run on for a fortnight, through the whole of which, although 
exacerbations and remissions may occur, the patient will be unable to lie 
down ; and has to sustain himself by leaning forward on some kind of 
support. When the paroxysm ceases, he is quickly restored, and like one 
who has gone through an attack of gout or dyspepsia, feels unusually well. 
Referring to monographs of the disease for the many symptoms here 
omitted, and especially for their modification by the supervention of organic 
lesions as the disease advances, I proceed to say a few words on its pathology. 

It is evident, I think, that this is what we call a functional disease, and 
equally evident that it is not one of the phlegmasise. Its history seems to 
mark it as a pulmonary neurosis, accompanied in general with passive con- 
gestion of the mucous membrane. In many persons this catarrhal state is 
so slight that all the symptoms may be said to declare disordered motor 
innervation. I think with Dr. Bree, that the nerves which preside over the 
mechanical movements of the chest are involved ; but go further, and adopt 
the opinion that those bestowed on the bronchial tubes are likewise implicated; 
for, without the admission of spasmodic action in those tubes, I see not how 
we can explain either the sibilant rales, ever varying in place, or the extreme 
degree of dyspnoea. In this tubular affection branches of the pneumogastric 
are probably involved, while other branches bestowed on the stomach asso- 



INTERIOR VALLEY OF NORTH AMERICA. 837 

ciate the two organs in the sufferings of the paroxysm ; or give to gastric 
irritation the power of exciting bronchial and thoracic spasm. I shall pursue 
these speculations no further, but proceed to say a few words on the treat- 
ment. 

IV. Palliatives. — As in the case of hooping-cough a very great 
variety of remedies have been prescribed ; and, as in that disease, they have 
generally accomplished nothing more than imperfect palliation, yet whatever 
has been done has, if I am not mistaken, been accomplished by means which 
harmonize with the pathological views which have just been taken. In the 
earlier stages of the disease, I have frequently seen an emetic arrest the 
forming paroxysm; and in the more advanced, it often affords great relief. 
Mercurials, either the blue pill or calomel, to act on the liver, are necessary, 
but free or hydragogue purging is not advisable. Bloodletting is some- 
times demanded in a full habit and before the disease is far advanced, but it 
never puts an end to the paroxysm, and may even prolong it. Nauseating doses 
of ipecac, given with an equal quantity of calomel, or mingled in draughts of 
lobelia infusion, are useful. I cannot agree with Dr. Bree and Dr. Mackintosh, 
that opium should be avoided ; on the contrary, it may be advantageously com- 
bined with the medicines which have been mentioned, or with tartarized anti- 
mony in sub-nauseating portions. Equal parts of wine of ipecac, and paregoric 
often give relief. The acetate of morphia dissolved in spiritus Mindereri 
is equally useful. Another available antispasmodic is the tinctures of assa- 
foetida and opium combined ; another, the tincture of lobelia, with paregoric, 
or the tincture of hyoscyamus. It is necessary to invent many formulas ; for 
in this, as in the r acknowledged neuroses of the hysterical stamp, the nervous 
system soon loses its impressibility to one preparation. What gave relief 
yesterday will fail to day, while a new formula will succeed. As to the 
tincture of lobelia, I have been in the habit of employing it for more than 
thirty years ; not merely in the paroxysms, but between them, as a means 
of diminishing their frequency and violence; and although it has often failed 
of any appreciable effect, it has, on the whole, done more good than any 
other medicine I have tried. Rubefacient or narcotic frictions over the 
spine sometimes give relief, and when the sense of vesicular suffocation is very 
great, a large blister, should be applied to the anterior part of the chest. 
Now that an empiricism has broken down the popular prejudice against the 
use of water, I should not hesitate, in a case unaccompanied by organic 
lesions, to wrap the thorax in towels dipped in cold water, well knowing its 
power in controlling spasmodic action. As to the inhalation of the smoke 
of stramonium leaves and other narcotics, I can say nothing conclusive 
from my own experience. 

The treatment between the paroxysms should be hygienic and corroborant. 
It is especially necessary to attend to the digestive organs, and to avoid all 
known exciting causes, while everything which can increase the vigor of the 
system will be proper. I have no room for details, and will only add, that 



838 THE PRINCIPAL DISEASES OF THE 

when the paroxysms are frequent and refractory, it would be well for the 
patient to try a change of place, seeking one which in its climate and other 
conditions differs as much as possible from that in which the malady origi- 
nated, or returns with violence. If, for example, he should be residing in 
a malarial region, he should try the depths of the city : if in the latter, seek 
a salubrious residence in the country. 



SECTION IV. 

HAY- ASTHMA — SUMMER CATARRH — CATARRHUS ^ESTIVUS. 

I. I have already referred to this rare affection, when giving the etiology 
of our pulmonary phlegmasise — stating that I had seen but two cases. The 
British writers (Bostock, Elliotson, and some others) regard it as com- 
pounded of asthma and catarrh. Taking its elements from what I have 
seen, coryza and asthma would be a better expression, for the symptoms of 
a cold in the head predominated over the affection of the air passages below, 
which might be said to have been in an asthmatic condition. The annual 
periodicity of this disease is one of its most distinguishing characteristics. 
In England it generally returns in the end of spring, or the beginning of 
summer, the time of hay-harvest in that climate. I do not propose to go 
into its foreign history, but for the purpose of showing its character in our 
Valley, and of directing attention to it, will give an outline of the cases 
which have fallen under my own observation. 

II. Dr. P. S. C, of this city, was born in 1811, near Newburyport, Massa- 
chusetts, close to the sea, where common asthma is rather prevalent. His 
parents, brothers and sisters were free from any pulmonary affection. He 
was regarded as having, from birth, rather a feeble constitution. When six 
years of age, 1817, he went through the measles, and his present disease 
followed on that, recurring annually, once only, down to the present au- 
tumn (1851). He continued to reside in his native state till he was twenty- 
two years of age. During that period, the recurrence was in August, 
and the attack generally lasted from four to six weeks, but was sometimes 
shortened by going from the sea-shore into the interior. When he was 
about seventeen years old, his asthmatic wheezing was louder than before or 
since. While in Massachusetts the attacks came on more suddenly than 
when he went further south, and seemed to be excited by the beginning of 
cool nights. His first emigration (1833) was to the town of Westchester, 
Pa., near Philadelphia, where he resided five years, and where the attacks, 
dated a little later in the seasons, were less violent, and not so long as in 
Massachusetts, three degrees further north. In 183-, he removed to 
Camden, near the Dismal Swamp, North Carolina. After reaching there, 
he was seized with intermittent fever in the month of July, and had 
repeated attacks for the ensuing eight months; his annual visitor returned, 



INTERIOR VALLEY OF NORTH AMERICA. 839 

however, as usual, and did not seem modified in character by the malarial 
disease. After residing there three years, and finding his malady not 
arrested by the warm climate, he left for Cincinnati, where he has resided 
eight years. The attacks here commence gradually about the middle of 
September, and continue from two to four weeks, with less violence than 
they had in Massachusetts. 

III. Symptoms. — The paroxysm invariably commences with itching in 
the nostrils, and a sense of fulness, as if the nares were plugged up with 
polypi; sneezing, and a constant dripping of transparent acrid fluid imme- 
diately supervene, the mucus, after several days, becoming thicker and 
opaque. Yery soon a troublesome itching, with a little aversion to light, be- 
gins in his eyes, which show more or less of sanguineous congestion, but 
without uniformly increased mucous or lachrymal secretion, for the con- 
junctivas feel dry. The discharge from the nostrils is diminished through 
the night, and has irregular periods of remission and exacerbation in the 
day. These symptoms constitute, as it were, the first stage of the attack. 
They are ushered in without any precursory indisposition, loss of appetite, 
or attendant chill and fever. 

In eight or ten days, the coryza ceases, or greatly abates, and is replaced 
by the pulmonary or bronchial affection. This begins with dyspnoea and a 
sense of oppression or tightness in the upper part of the chest, attended 
with a dry, hoarse cough, which was more severe in Massachusetts than it 
is in Ohio, but is unaccompanied with pain or fever. Sometimes he expec- 
torates a little mucus ; but never has the profuse bronchial secretion so 
characteristic of humoral asthma. The dyspnoea is often so great as to 
compel him to sit up all night, feeling, at the same time, in other respects 
quite well. 

This gentleman first called on me in July of the present year, 1851, when 
I collected from him the foregoing history. He was then free from the 
disease. His frame was rather slender, his chest not capacious, but well 
formed, his flesh moderate, his hair black, and his complexion somewhat 
muddy and sub-sallow. His pulse was sixty, and his breathing eighteen, in 
a minute. Under a careful examination by percussion and auscultation, I 
could detect no abnormal sounds either in the lungs or heart. Three weeks 
afterwards he called again, in the fifth day of his annual attack of coryza. 
The symptoms were those which have been given. The bronchial had not 
yet come on. His pharynx and palatal arches exhibited a little redness. 
His tongue was healthy. He had no fever. Soon after this he started for 
Massachusetts, and thence went to North Carolina, being gone three weeks, 
and thus depriving me of the opportunity of inspecting his chest during the 
bronchial stage of the disease. It was not quite over, however, when he 
returned, and I found the bronchial sounds in the upper part of his lungs 
louder than when I examined him before. They were dry. His attack 
had been worse than usual, which he ascribed to the dust of the railway, 



840 THE PRINCIPAL DISEASES OF THE 

and the bright light to which he had been exposed ; his eyes always feeling 
best in a room a little darkened. His pulse at this time was eighty-four, 
his mouth and fauces dry, his cough strongly paroxysmal, and without 
expectoration. 

IV. Treatment. — Dr. C. has tried various remedies, but with so little 
benefit that he now seldom does anything. Bloodletting, both general and 
local, has seemed to do harm rather than good. Antimonial emetics and 
nauseants, and purges of calomel and jalap have equally failed. For the 
dyspnoea, blistering has done more than any other remedy. He has not 
tried inhalations. Three years ago, just before the attack, he resorted to 
sulphate of quinine, and took a drachm in three or four days. It did not 
ward off the disease ; but its duration was less than usual. 

[References to three other cases are given, and a memorandum of an 
intention to describe the decline of the disease is inscribed on a blank page.] 



CHAPTER XIV. 

ACUTE AND CHRONIC BRONCHITIS— BRONCHIAL CONSUMPTION. 



SECTION I. 

ACUTE BRONCHITIS. 

I. Symptomatology. — The extent of mucous surface which may be and 
commonly is involved in this phlegmasia is so much greater than that im- 
plicated in laryngitis, that, looking to that only, one might suppose its 
history must be correspondingly more extended ; yet such is not the case, 
for the simplicity of structure and function of the bronchise are so great, 
compared with the larynx, that the diagnosis is far easier, and the modes of 
lesion are much fewer. 

Bronchitis, like pulmonary catarrh, of which it is in fact but the inflamma- 
tory grade, sometimes begins with coryza; but in other cases, the bronchial 
tubes are affected first, or no coryza may be present throughout the attack. 
An ingravescent catarrh may end in bronchitis, without the intervention of 
a chill or sudden access of fever, and many lives have been lost from not 
knowing or recollecting this fact. At other times, and, perhaps, more fre- 
quently it is ushered in by a chill, with sharp febrile reaction ; the pulse, 
however, not attaining the hardness which characterizes serous inflamma- 
tion. Cough exists from the beginning, but does not awaken the pleuritic 
stitch. A general sense of thoracic constriction, more or less tense, is con- 



INTERIOR VALLEY OF NORTH AMERICA. 841 

stantly present. Pains of an obtuse and deep-seated character are soon felt 
in various parts of the chest at the same time, but not long in one place. 
They frequently attack also the muscles of respiration, which are easily 
excited to action, and hence a full or rapid inspiration always brings on 
cough. At the beginning of a sudden invasion there is little or no expec- 
toration ', but generally within twenty-four hours mucus is thrown up. At 
first it is little altered, but soon loses its transparency, and in all violent 
cases presents streaks of blood. "With the progress of the disease, and 
especially in the declining stages, it is sometimes profuse. When the 
attack is protracted, pus becomes blended with the mucus ; but this belongs 
more properly to the chronic form. The patient commonly lies as well on 
one side as the other, but prefers to have his head and shoulders raised. 

The symptoms which have been enumerated leave no doubt as to the 
existence of acute bronchitis \ yet recourse may be had to the physical signs. 
Under percussion the resonance of the chest is nearly or quite normal. 
Auscultation, however, reveals in the beginning sibilant and mucous rales, 
more or less mixed up; but subsequently a great predominance of the 
latter. The vesicular murmur is often unheard in consequence of the loud 
sounds formed in the bronchial tubes. It can best be heard near the base 
of the lung. This method of examination, although not necessary to a 
knowledge that bronchitis exists, is of importance, indeed, is the only reli- 
able means for ascertaining its extent. Thus, by travelling over the chest, 
we decide as to the presence or absence of bronchial inflammation in the 
different parts of the lungs. Another important use of the stethoscope is 
to inform us whether the inflammation is passing from the tubes into the 
surrounding areolar tissue, or into the air vesicles, thus adding pneumonia, 
with its crepitant rattle, to the previous inflammation ; last, when, as some- 
times happens, a bronchial tube becomes so plugged up that no air can pass 
along it, the condition is detected by the absence of sound from that part of 
the lung while it still retains its resonance. 

In coming to a favorable termination, the pulse becomes slower, and 
more equable, the fever abates, the thoracic stricture is relaxed, the ex- 
pectoration becomes profuse, the skin moistens, and the patient inclines to 
sleep. On the other hand, when it goes on to an early fatal termination, 
the pulse loses its volume, increases in frequency, and becomes struggling 
and irregular, the dyspnoea becomes anxious and distressing, the cough often 
fails to effect expectoration, and the mucous rale increases, while the chest, 
from the filling up of the bronchial tubes and their terminal vesicles, and 
also from increase of congestion, loses a portion of its resonance ; the patient 
requires to be propped up in bed, and from defective aeration of the blood, 
his lips, nails, and other parts of the surface display a dusky or smoky hue. 
With these symptoms he dies by slow asphyxia, aided by the sympathetic 
influence which the lesion of any great organ exercises on all the rest, through 
the medium of the nervous system. 



842 THE PRINCIPAL DISEASES OF THE 

II. Lesions. — The essential characteristic lesion of acute bronchitis is 
hyperemia, with thickening and softening of the affected membrane. The 
tubes abound in mucus, which the patient, for a time before death, was 
unable to expectorate. In some places there are patches of unadherent 
coagulating lymph. A purulent secretion is generally mingled with the 
mucus, the pus being secreted by the inflamed membrane. A partial pneu- 
monia around the tubes may leave the characteristic lesions of that disease ; 
and when the air-cells have been invaded, the lesions of pneumonia are found 
there also. The part of the lung in which these latter lesions exist may 
sink or swim in water, according to the amount of unsolidified tissue taken 
off with them. From the carbonized state of the blood, all the tissues are 
more or less deepened in color. 

III. Cure. — The first blood drawn in this disease is not always buffy. 
Several bleedings are occasionally necessary, yet a second is frequently 
sufficient. On the whole less venesection is required or borne than in pneu- 
monia and pleurisy. Aged and infirm persons, in whom the congestion may 
be largely uninflammatory, pneumonia notha, will sometimes not bear a 
single bleeding. From the difficulty of bleeding little children, bronchitis 
often destroys them. One bleeding, however, is in general sufficient, if 
carried to impending syncope. Afterwards the case may be trusted to anti- 
phlogistic alterants, which without the loss of blood would have produced 
but little effect. Cupping is a common remedy, but from the manner in 
which the mucous membrane is insulated from the parietes of the chest, we 
may doubt whether it can produce much salutary revulsion. A large blister, 
acting through the nervous system, promises more, and after adequate vene- 
section often gives great relief to the dyspnoea. 

In the early stage, an active emeto-cathartic, of calomel, jalap, and tar- 
tarized antimony, or powders of the first and last with nitrate of potash, 
are followed with happy effects. It is important to carry off the existing 
contents of the stomach, bowels, and liver, and to make diversion from the 
lungs. In the beginning alvine evacuation will not interfere with that ex- 
pectoration which is the natural cure of the disease ; and subsequently the 
regular action of the liver, and a soluble state of the bowels, are all that 
should be aimed at in the use of aperients. 

The great medicines in this disease are the nauseants and the unstimula- 
ting expectorants. The most important of the whole is tartarized anti- 
mony, as being sedative, alterant, and promotive of bronchial secretion. It 
may be given alone, or combined with tincture of digitalis or lobelia. I 
have generally used the former, and found it a valuable adjuvant to tartar 
in subduing this inflammation. It should be continued till the pulse feels 
its peculiar enfeebling influence, and then as its effects are cumulative and 
somewhat enduring, should be laid aside, lest the powers of the heart might 
be too much depressed. Ten drops with an eighth of a grain of tartar, in 
mucilage every two hours, may be regarded as a medium dose. But calo- 



INTERIOR VALLEY OF NORTH AMERICA. 843 

mel should not be overlooked in this inflammation, and it may be advanta- 
geously combined with squills, two grains of each in a pill, being given 
every two hours, or every four hours, alternately with the other compound. 
The four medicines here advised, I have found more valuable than all others. 
Their effects will be augmented by the use of warm mucilaginous or acidu- 
lated drinks. During their administration the patient may occasionally 
vomit. To this there is no objection; and indeed whenever the bronchiseare 
much clogged with mucus, vomiting will be one of the most certain means 
of relief. 

At a certain stage, more or less early according to the temperament of the 
patient and the degree of bloodletting premised, we may begin the combi- 
nation of opium with these medicines. It is required to allay irritability, 
appease the cough, procure sleep, and determine the action of the nauseants 
upon the skin. Thus managed, expectoration may be temporarily suspended, 
but the secretion of mucus, and consequent resolution of the inflammation, 
will not, for moisture of the skin is highly favorable to bronchial secretion. 

Such is the method which I have long found successful in acute bronchitis; 
but there is a stage or state of the disease which requires other remedies. 
When the powers of the system have begun to fail and the expectoration is 
not free, the transmitting function of the lungs also fails, and they become 
doubly engorged with mucus and blood. With a weaker pulse, the patient 
feels increasing dyspnoea, and becomes anxious and restless. His tongue 
at the same time has lost its white color, and his mouth as well as his skin 
becomes dry. We must not confound this condition with that produced by 
an unsubdued and disorganizing inflammation leading to great depression 
and a livid or smoky hue from the state of the blood, and which is in gene- 
ral fatal. 

The former condition is not necessarily so, and should be met by stimu- 
lants, especially those which experience has taught us act somewhat specifi- 
cally on the lungs — the stimulating expectorants. Every physician will 
form his own compound in this emergency. I will mention those which I 
have found most efficacious. Boluses of carbonate of ammonia and camphor 
made up with balsam copaiva ; a linctus of oil of turpentine, loaf sugar, and 
gum Arabic ; lac ammoniac and carbonate of ammonia ; lastly, an infusion 
of seneka root with tincture of assafcetida. To each and all of these com- 
pounds Dovers' powder or some other preparation of opium should be added. 
The inhalation of aqueous vapor or that of vinegar is also useful in this 
condition. If the feet should fail in temperature, they should be placed in 
a stimulating bath ; and sinapisms to the epigastrium or chest are often 
beneficial. This pathological condition is, except in highly lymphatic tem- 
peraments, of transient duration, and as the patient emerges from it, the 
treatment recommended for it should be gradually laid aside. As to the 
other pathological state which shows the blue complexion, I know of no 
better treatment than that which has been laid down, though a successful 
result should not be anticipated. 



844 THE PRINCIPAL DISEASES OF THE 

Acute bronchitis does not always terminate in immediate restoration to 
health or in death; but oftener than many other phlegmasia subsides into 
a mild or subacute inflammation. Bronchitis may indeed be of that grade 
from the beginning, and the union of these two kinds of cases makes up the 
form of disease denominated chronic bronchitis, to which we must now give 
attention. 



SECTION II. 



SUBACUTE OR CHRONIC BRONCHITIS. 



I. Everf case of bronchial or catarrhal consumption, is in fact a case of 
chronic bronchitis ; but every instance of the latter is not an example of 
the former. It is not until certain symptoms appear that the term consump- 
tion can with propriety be applied to a case of chronic bronchitis. These 
symptoms are not of sudden but slow development; and are as it were a 
transformation of those which have existed for some time. They are partly 
found in the pulmonary manifestation and partly in the type of the accompa- 
nying fever. The sputa become more purulent, and the fever, assuming a 
more remittent or intermittent character, is preceded by chilliness and 
followed by perspiration. It is not till a time somewhat remote that the 
physical signs materially vary. It is the duty of the physician if possible 
to avert this change, by arresting the progress of inflammation before the 
phenomena of consumption have become developed, and to that object we 
must first give attention. 

II. It is scarcely necessary to devote much time to the symptoms of 
chronic bronchitis, when they are in fact but diminutives of those which 
characterize the acute forms of that disease. I know of no malady with which 
it is likely to be confounded. The patient is generally able to be on his 
feet and go abroad, though exposure is exceedingly apt to aggravate all his 
symptoms ; hence he bears the cold badly, and is improved by warm weather 
or by going to a milder climate. In summer the disease may cease entirely 
but return with the first cool weather of autumn, constituting what is called 
a winter cough. The aged are more liable than the young to such attacks, 
which may return annually for many years. I have at this time a female 
patient who has been affected for more than twenty years, in some of which her 
life was in danger, but the warm and settled weather of spring has uniformly 
brought relief. Such annual returns remind one of the yearly recurrence 
of hay-asthma. 

III. The remarkable influence of the weather on chronic bronchitis greatly 
opposes our treatment, which for half the year in many cases can achieve 
nothing more than palliation, but that is often a great deal, seeing that 
without it the patient would die. Now the means of palliation and of cure 
are substantially the same; and scarcely differ, save in degree, from those 
required in the acute stage of the disease. The hygienic regulations or 



INTERIOR VALLEY OP NORTH AMERICA. 845 

regimen are now, however, of much moment. Exposure to a cold, moist, or 
changeable air, sitting in the wind, or sleeping in damp apartments, must 
be carefully avoided ; and the feet especially should be kept warm and dry. 
Tepid bathing, with frictions over the chest to make revulsion to the sur- 
face and maintain the functions of the skin, are useful. The diet should be 
restricted, unirritating, and liquid, meat and condiments being excluded, 
and milk or buttermilk made a portion of every meal. All active exercise, 
lifting, and loud speaking should be prohibited. Finally, every kind of 
impure or confined air which might make a sinister impress on the inflamed 
membrane should be avoided. By carefully observing these regulations, 
the disease will often be subdued with very little or without any medicine, 
while to disregard them is to nullify the effect of all medication. 

The lancet is not so often employed in this disease as it should be. The 
heat of the skin which so frequently guides us in the diagnosis of fever, is 
often absent in this malady, when the firmness of pulse and the inefficacy of 
our medicines indicate such a phlogistic diathesis as calls for venesection. 
Even in the winter bronchitis of the aged a copious bleeding is frequently 
of very great advantage. The blood will be sizy, although no increase of 
heat suggested fever. When pain seems fixed in any particular part of the 
chest, cupping with scarification will be proper ; and extensive dry cupping 
may do something, perhaps, towards revulsion. 

No remedies are more constantly resorted to in this disease than counter- 
irritants. I have not found them so beneficial as they seem to have been 
in the hands of others. When there is fixed pain or a general feeling of 
stricture, a blister may do good ; but its incessant repetition is of doubtful 
propriety. Adhesive plasters sprinkled with tartar emetic, often lead to 
deep and painful ulcers, for which I have never seen any compensating 
benefit. An extensive application of tartar ointment continued so as to 
maintain for a while a slight but widespread pustulation, is I think, the best 
mode of counter-irritation. 

The stomach, probably from sympathy with the lungs or liver, is fre- 
quently deranged in its function; but the liver, I think, still oftener. This, 
it is possible, may arise from the obstructed passage of blood through the 
lungs, whereby the ascending cava, overcome as it were by the descending, 
is not able to discharge its blood in due time, and thus the liver may become 
engorged. In this condition, the secretion of bile is sometimes morbidly 
increased; at other times suspended; while both conditions disturb the 
functions of the stomach. For the first, simple purgation is all that is re- 
quired ; for the second, such means as will revive the secretion, should be 
employed. Of these, the best is a pill composed of one grain of calomel 
and five of extract of taraxacum, given every four, six, eight, or twelve 
hours, according to the exigency of the case. By taking the last term so 
as to give two grains of calomel in the twenty-four hours, a slight consti- 
tutional effect may at length be produced with advantage to the lungs. 
As an external remedy in these cases the nitro-muriatic solution applied 



846 THE PRINCIPAL DISEASES OF THE 

with a sponge over the region of the liver, is useful ; and if it be carried 
over the chest, so as to produce a rubefacient effect, the benefit will be still 
greater. 

Of alterants and expectorants, we possess a number. The decoction of 
polygala senega, two ounces, three or four times a day, is beneficial; the 
tincture of sanguinaria canadensis, or bloodroot, in drachm doses, disguised 
in syrup or mucilage, may be advantageously exhibited at the same inter- 
vals; the tincture of lobelia inflata, in half-drachm doses, at the same 
periods, is likewise reliable ; the tincture of squills, in 20 or 30 drop doses, 
given in a solution of nitrate of potash, several times a day, is valuable not 
only for its action on the lungs, and as a sedative on the arterial system, 
but from its diuretic effects, whereby diversion is made from the inflamed 
membrane ; the balsam copaiva, when pure, and especially if enveloped 
in capsules of gelatin to conceal its offensive taste, is also valuable as exert- 
ing an influence on both the lungs and kidneys. Thus we have an ample 
catalogue out of which to choose, but the compound of tartarized antimony 
and digitalis, given in the manner recommended when treating of chronic 
laryngitis, has been more efficacious in my own practice than any of the 
medicines which have been named. 

To all these recipes it will be necessary, from time to time, to add more 
or less of the preparations of opium. This is especially required in the 
evening to suspend the cough during the night, and throw the function of 
expectoration upon the morning, which is physiological. We must not 
overlook the fact, moreover, that coughing irritates the inflamed membrane, 
and should therefore be restrained within the limits necessary to expectora- 
tion. Opium also allays the spasmodic action of the bronchial tubes, which 
sometimes interferes with an easy ejection of their contents. Finally, there 
is reason to believe that when inflammation, especially of the mucous mem- 
branes, is reduced to a certain point, opium, by allaying irritation, may 
carry on the reduction, and thus prove antiphlogistic and curative. 

In this affection our salino-sulphurous waters are sometimes serviceable ; 
but to be made so, their inordinate action on the bowels and liver should 
be restrained, and turned upon the skin and mucous membrane of the bron- 
chi. To this end, opium, especially at night, with external warmth will be 
necessary. The waters themselves will prove sudorific and expectorant if 
they can be kept from acting on the bowels. 

The last curative means which I need to mention is a Southern residence, 
from the beginning to the end of the cold and variable weather, concerning 
which, I will say more under the next head. 



SECTION III. 

BRONCHIAL CONSUMPTION. 

I. In the first division of the last section, I gave an outline sketch of the 
symptoms of bronchial consumption as compared with those of chronic bron- 



INTERIOR VALLEY OF NORTH AMERICA. 847 

chitis. This piece of diagnosis may be made perplexing, by seeking for 
what does not exist, if we look for a sudden change of symptoms, indicating 
an equally sudden pathological change. But if we bring the phenomena of 
the early stage of chronic bronchitis and those of the latter stage of bron- 
chial consumption together, and, after contrasting them, imagine a progres- 
sive conversion of the antecedent into the subsequent, we shall relieve our- 
selves of much embarrassment. Bronchial consumption is, in fact, but the 
well-developed suppurative stage of chronic bronchitis, and bearing the same 
pathological semeiological relation to it, that the purulent secretion, hectic 
fever, and emaciation connected with a large cellular abscess bears to the 
inflammation and phlogistic fever which produced it. Now in this latter 
case, as the first fever declines with the secretion of pus, the second begins 
to arise ; or, after the lapse of a little time, sets in. At the beginning it is 
slight, but gradually increasing, it comes at length into full development ; 
and such is the course of events in suppuration of the bronchial membrane. 

II. In the preceding section I said nothing of the lesions of chronic bron- 
chitis, reserving them for this place. They consist essentially of hypere- 
mia, thickening, softening, and incipient ulceration, with more or less ex- 
tension of inflammation through the tubes, and consequent disorganization 
or hepatization of the areolar tissue around them, and of a similar implica- 
tion of the vesicles of some of the lobules. At the same time, even when 
no ulcerative absorption has taken place, pus is found intermingled with the 
abounding mucus. Now, in bronchial consumption we have all these lesions 
in an aggravated degree, especially the ulceration, with superadded hyper- 
trophic dilatation of one or many bronchial tubes ; and very often an obli- 
teration of the cells in which the dilated tube has its termination. This 
obliteration may be consequent on an obstruction or obliteration of the tube 
below the dilatation, or the cells may be first obliterated, and the tube then 
dilated from the air being prevented from passing through it to the lobules. 
In either case the latter become atrophied, and not supporting the cells of 
the surrounding lobules, they may be ruptured in deep inspiration, and a 
portion of air may escape into the areolar tissue, adding emphysema to the 
previous lesions. I have said that the pulmonary tissue round an inflamed 
tube is apt to participate in the disease and become hepatized ; but the 
inflammation abating in violence as it does with the progress of suppuration, 
the surrounding hepatized areolar tissue may undergo a change, and by 
absorption be brought into a state of atrophy, being reduced to a mere cel- 
lulo-fibrous structure, a condition which may increase the dilatation, by 
leaving the tubes unsupported. 

III. The diagnosis of bronchial consumption, after what has been said, 
may be thus summed up : Hectic fever ; purulent, or muco-purulent expec- 
toration, often exceedingly copious ; bronchophony simulating pectoriloquy 
in the dilated tubes ; with considerable emaciation. Of course dyspnoea, 
wandering pains, occasional stricture, cough under a deep inspiration, 



848 THE PRINCIPAL DISEASES OE THE 

mucous rales, and a predominance of the bronchial over the vesicular sounds, 
are present, but they belong equally to the earlier stage of the disease, to 
which I have restricted the terms chronic bronchitis. But if the phlogistic 
and hectic stages of bronchial disease be thus sufficiently distinguished, how 
are we to decide between the latter and tubercular suppuration or true 
phthisis ? As far as the physical signs are concerned we may, by changing 
the position of the stethoscope, ascertain whether the cavity in which vocal 
resonance is heard have an oblong, or more circular figure; the former 
indicative of tubular, the latter of cavernous resonance ; then, the latter is 
much oftener filled up with morbid secretions than the former, and during 
that condition will emit no sound j still further, when empty it admits 
cavernous or amphoric sound in respiration, while that of the dilated bron- 
chus is still bronchial. But if the most eminent stethoscopists — the atten- 
dants on great hospitals — those who make pulmonary diseases a specialty, 
have fallen into errors of diagnosis when relying on the physical signs, the 
great mass of general practitioners should look beyond this method, and 
happily they can generally find reliable guidance. When treating of the 
production of a tubercular diathesis, remarks will be made which are appli- 
cable here. The individual having or prone to that diathesis is not liable 
to bronchitis, as the man of broader frame, more expanded chest, and less 
bulky muscles. Then again, he has family predispositions to phthisis, which 
the other has not. Still further, early and constantly increasing emaciation 
never fails, but in bronchial consumption the atrophous tendency is far less. 
Summer, moreover, often brings great relief; and sometimes the patient will 
regain much of his lost flesh, finally (though a diagnostic fact), out of time he 
may go on to complete recovery. I have never seen tubercular phthisis without 
great emaciation, nor bronchial phthisis with it. The lesion of the protein 
elements of the blood, such an essential condition in tubercular consump- 
tion, and so explanatory of the emaciation, is not in fact present in bronchial 
consumption. Several winters ago, my attention was accidentally turned to 
a patient walking about the wards of the Louisville Hospital, who the 
students told me labored under tubercular consumption, and had passed the 
preceding winter in the hospital. His appearance made me incredulous as 
to the diagnosis that had been pronounced, chiefly on the alleged pecto- 
riloquy. He was broad rather than tall, had a well-developed chest covered 
with a good amount of flesh, and the muscles of his extremities had conside- 
rable bulk and firmness. When he died some time afterwards, not a tubercle 
of any size was found in his lungs, which displayed only the lesions of bron- 
chial inflammation. 

IV. Having settled the diagnosis, the question is how should the case be 
treated ? Before replying, I may remark, that while the treatment of tuber- 
cular phthisis is only palliative and sustaining, that of closely simulating 
disease, may be curative ; in other words, there is often, if not generally, 
ground of hope that the patient may recover, and we prescribe accordingly. 



INTERIOR VALLEY OF NORTH AMERICA. 849 

Of all remedies, the most important in this as in laryngeal phthisis, is a 
southern climate. The patient should, if possible, get out of the region of 
catarrh, and bathe for six or seven months of the year in a warm and more 
genial atmosphere. The further he lives north in our Yaliey, the earlier in 
autumn should he leave home, the later return in spring. When our woods 
have put on their autumnal hues, and no frost has yet been sharp enough to 
freeze off their dying leaves, the invalid should be off; and not return in 
spring till the same woods are clothed in green. But, like a bird of pas- 
sage, both his going and returning should be gradual. He should just keep 
ahead of the cold weather of autumn, and the hot weather of spring. To 
go with rapid speed from a high to a low latitude, is not salutary, and to 
ascend suddenly from a region of great heat to one much cooler is still 
worse. A neglect of these various rules has rendered many a trip abortive 
of all benefits j or even made it worse than remaining at home. Thus, it 
frequently happens that patients, on their way to the South, are retarded or 
arrested by the ice, while descending the Missouri, the Upper Mississippi, 
or the Ohio; this is a dangerous exposure, and to have remained at home 
till the winter sets in, for such ice is never generated till December is consider- 
ably advanced, is a mischievous absurdity. Then in March, to be deluded 
by the heat and full vegetation around them, and, with steamboat speed, 
return through ten or fifteen degrees of latitude, to encounter the cold rains, 
northern winds and frosts, where the heat has not yet been great enough to 
unfold the forest leaves, is to give to those atmospheric conditions, an influ- 
ence much more pernicious than if the patient had wintered at home. As 
to sojourning far in the South throughout the summer, it is not to be com- 
mended. The patient goes there not so much for the curative effects of 
high temperature, as to escape the aggravating influences of a cold and vari- 
able atmosphere ; and if he should continue there throughout the summer, 
he might be greatly enfeebled. Cool and fresh air is necessary to sustain 
him under the suppurative diathesis, and he may even, with much advan- 
tage, spend the summer months in a higher latitude, as at Mackinac, at Fort 
Snelling, or on the banks of the St. Lawrence ; indeed, from the sources of the 
Mississippi down to Quebec, places of summer sojourn and travel are numerous 
and available.* But let us return to the South, and inquire into our resources 
for winter accommodation. I am sorry to say that they are not very good. The 
winters of New Orleans, Mobile, and Pensacola are wet, and spells of weather 
quite too cool for pulmonary patients are perpetually occurring. G-alveston, a 
little further south, is too limited for exercise, is subject to the " northers" 
from the Sierra Madre, and, although an island, is too near the continent to 
present the equability of a true insular climate. Tampico and Yera Cruz 
enjoy a more appropriate climate, but are deficient in accommodations. 
Tampa Bay and Fort King have climates more favorable than those of the 

* See Book I. 
vol, ii. 54 



850 THE PRINCIPAL DISEASES OF THE 

\ 

northern shores of the Grulf, but are as yet too newly settled. Key West 
has a milder climate than either, but admits of very little exercise. Finally, 
the interior and more southern coasts of the island of Cuba present greater 
advantages than any other locality within our reach. I do not mean to say 
that it may not be better for a patient with bronchial consumption to winter 
in Louisiana, than Michigan, Illinois, or Kentucky, but that all the benefits 
of a southern voyage are not to be found there. As to the best localities of 
that region I cannot speak with confidence, but incline to the opinion that 
the " coast," or river bank, above New Orleans up to Donaldsonville, would 
be preferable to that city, Mobile, or Pensacola, notwithstanding the latter 
has been a chief place of winter resort. 

Exercise, necessarily involved in travel for change of climate, should not 
be limited to that amount nor that degree which, by steamboats and rail- 
roads, is little more than passive or gestatory. Whenever the patient has 
the means, he should travel by land in a carriage or on horseback, taking 
water only when necessary to his reaching a certain point. In a carriage, 
he should himself be the driver so as to exercise his arms and chest. But 
of all modes the equestrian is perhaps the best, provided with means of 
warding the rain that may chance to overtake him. When the circum- 
stances of the patient do not admit of his leaving home, he should, when- 
ever the weather will permit, make neighborhood jaunts, or engage daily in 
the labors of the field or shop, the former in fair, the latter in foul weather ; 
but he must do nothing, or not push anything so far as to hurry his respi- 
ration or produce dyspnoea. It is not quick, but slow and strong muscular 
movement, that is to bestow the vigor which will diminish purulent secre- 
tion, give the bronchial ulcers a disposition to cicatrize, and diminish that 
irritability of the heart which tends to keep up his frequency of pulse.- 
Exercise, moreover, facilitates expectoration, and relieves the lungs from 
the reactive influence of a heterologous secretion. 

The diet in bronchial consumption should not be as low as in the stage 
to which we have limited the terms chronic bronchitis. There may, 
indeed, be periods of inflammatory aggravation, when great abstemiousness 
will be demanded ; but in their absence the diet should be of a restorative 
kind, consisting of good bread and easily digested vegetables, milk, cream, 
and a daily meal of meat, all surfeiting being carefully avoided. 

The medicines given in this disease should harmonize in their effects with 
those of the exercise and diet which have been indicated. Those which are 
given as expectorants should not be of the same debilitating kind recom- 
mended for chronic bronchitis; the antimonial preparations especially should 
be but little used. The tincture of lobelia and the tincture of digitalis are 
two of the best. The compound tincture of benzoin is now in place, and 
starts with a good though empirical character, as being the successor of the 
old-fashioned balsam of life. A mixture of two parts of this medicine with 



INTERIOR VALLEY OF NORTH AMERICA. 851 

one of tincture of digitalis, in the dose of thirty drops three or four times 
in the twenty-four hours, is often beneficial, seeming to act as a tonic to the 
bronchial tubes. Myrrh is also useful, and as chalybeates are not only 
admissible but beneficial, the mistura ferri composita finds here, perhaps, 
its most appropriate place. The syrup of iodide of iron is also well adapted 
to this disease. Our wild cherry (Primus Yirginiand) is another medicine 
deserving of considerable confidence. A cold infusion of the bark, by dis- 
placement, is the best preparation, as on the hydrocyanic acid, which it then 
contains, a part of its good effects depends. If, however, a scruple of the 
finely powdered bark should be mingled with each dose of the infusion, its 
tonic properties will be much increased. A more reliable tonic still is the 
cinchona bark, which may be given in ale or porter, or made into a decoc- 
tion and acidulated with elixir vitriol, a prescription which is thought, and, 
perhaps, not without some foundation, to diminish the morning sweats. 
They are more or less mitigated by the avoidance of tartar emetic, ipecac, 
and other expectorants which act as sudorifics ; but a more positive mode of 
abating them is to make a strong revulsion upon the kidneys by stimulating 
diuretics, such as balsam copaiva, oil of turpentine, oil of juniper, and spirit 
of nitrous ether. An emulsion of copaiva with the spirit of nitre, although 
offensive to the taste, is one of our best compounds. In furtherance of the 
same object, the patient may take occasional draughts of gin and water, or 
black tea, which to many persons in health is so great a diuretic that they 
have to refrain from its use. The state of the liver and bowels should 
receive attention in every stage of this malady, and the means recommended 
in the preceding section be employed when deemed necessary. Finally, 
opium is required throughout the whole course of treatment, and the solid 
drug is, I think, preferable to any of the preparations of or from it. It 
acts on the skin less than paregoric or the salts of morphine, and is more 
gradual and permanent in its effects than laudanum. It promotes absorp- 
tion and diminishes the secretion in the bronchial membrane, but does not, 
as far as my own experience instructs me, diminish the action of diuretics; 
it suspends or appeases the cough, diminishes the irritability of the heart, 
and the frequency, while it increases the fulness of the pulse, and being 
administered in the form of half grain or grain pills, at regular periods, it 
even seems to co-operate with the tonics in maintaining or restoring the 
vigor of the patient, an indispensable step in the arrest of this as of other 
extensive suppurations with the hectic diathesis. 



852 THE PRINCIPAL DISEASES OF THE 

CHAPTER XV. 

PNEUMONIA AND PLEURISY". 



SECTION I. 

GEOGRAPHY, CHRONOLOGY, AND SUBJECTS. 

I. When we look at the Army returns, p. 790, we see that inflamma- 
tions of the respiratory mucous membrane are far commoner at our northern 
than southern posts \ while pneumonia and pleurisy (often mixed and 
oftener confounded), prevail more at the southern than the northern. Thus 
the average of all the northern stations is but fifty cases yearly, for a force 
of one thousand, while that of the southern is seventy-three. It is proper, 
however, that I should state, that in the statistics of his own practice, for five 
years, obligingly furnished me by Dr. Ames, of Montgomery, Alabama, the 
number of cases of acute bronchitis was 145, of pneumonia and pleurisy 
only 102. This discrepancy with the Army returns may, perhaps, be ex- 
plained by the military reports relating to men only ; while those of Dr. 
Ames included women and children, who are apt to be attacked with bron- 
chitis, under circumstances which produce pneumonia in men. As to the 
relative prevalence of that disease and pleurisy, the military returns show 
for our whole Valley, one case of pneumonia for one and seven tenths cases 
of pleurisy ; at the southern posts, one case of the former for two of the 
latter ; but in the practice of Dr. Ames, there were three cases of pneu- 
monia to one of pleurisy. How can this remarkable difference be explained ? 
Perhaps it indicates to us that pneumonia, as compared with pleurisy, is 
more frequent in childhood and old age than in middle life. We know in 
fact that the aged are more liable to pneumonia — younger adults to pleurisy ; 
yet Professor Gross* has seen well-ascertained pneumonia prevail as a sub- 
epidemic among children, when adults were but little affected. As to chil- 
dren, it is not easy to make a differential diagnosis ; I have observed, that 
before they die from acute pulmonary inflammation, a livid or smoky hue 
is generally developed, which indicates a parenchymatous lesion of the lungs. 
Still further, Dr. Ames's practice, not only included children and old per- 
sons, but a large number of blacks, and it may be that from the physiology 
of that race, they are more prone to inflammation of the interior than the 
serous covering of the lungs. 

It is undeniable, however, that pneumonia and pleurisy are not always 
correctly distinguished from each other, and in a multitude of cases, the 
disease is in truth pleuro-pneumonia or peripneumonia. I have scarcely 
ever made or been present at a post-mortem examination in these diseases, 
in which the ravages of both were not present. Pleurisy often conceals 

* Elements of Path. Anat., p. 434. 



INTERIOR VALLEY OF NORTH AMERICA. 853 

pneumonia. The acute pain in the side, with cough and fever, determines 
the diagnosis, and the associated pneumonia remains undetected. Some 
time since I was consulted by a gentleman from the country, who told me he 
had gone through an attack of pleurisy, but on submitting him to ausculta- 
tion and percussion, I found more than half his right lung in a state of 
hepatization. 

II. Pleuro-pneumonia may occur sporadically in every season of the 
year. According to our Army returns,* it prevails most in the first quarter, 
January, February, and March, and least in the third quarter, July, August, 
and September; the numbers being 31-7 cases in 1000 men, for the former, 
and only 74, for the latter. The second quarter presents 14, and the fourth 
17*2. Thus if we add the first and fourth together, so as to include with 
the winter months the first spring and last two fall ihonths, we have for the 
cold half of the year 49, for the warm half 21, or considerably less than 
half the number. I have monthly returns for three years from Dr. Ames, 
which give for the first quarter four times as many cases as for the second, 
six and a half times as many as for the third, and eight times as many as 
for the fourth. These statistics disclose that the pneumonic diathesis is 
generated by cold weather, and runs into warm, giving a much larger num- 
ber of cases from the winter to the summer solstice, than from the latter to 
the former ; in connection with which, it is worthy of being recollected that 
measles, although produced by a specific poison, prevails oftenest and most 
extensively in the same half of the year. 

III. Pneumonia occurs in every period of life from infancy to old age. 
It is, I think, most rapidly fatal in the two extremes of life. In the 
former period it is much more limited, often lobular, than in the latter, 
and at the same time more acute ; for in the aged it often presents the 
character of extensive sanguineous engorgement, without the symptoms or 
ravages of acute inflammation. This is, perhaps, the pneumonia notha of 
the older writers. My own observations coincide with those made in other 
countries, in showing this malady to be more frequent in men than in women, 
perhaps from their greater liability to the acute phlegmasia^ generally, and 
from their greater exposure to the well-known principal cause of the malady. 
For the same reason it is, I think, more frequent among the people of the 
country than the city, certainly among the laboring and exposed classes than 
any others. 

As pleuro-pneumonia may occur in every part of our Valley from the latitude 
of 48° down to 24°, as it is often engrafted on our typhous fevers, and quite as 
often complicated with a malarial diathesis, it follows that we should regard 
it as one of our most momentous diseases. What has just been said, sug- 
gests that we view it under three pathological and semeiological aspects ; first , 
as a simple phlegmasia, in which the phlogistic diathesis is unmodified ; 
second, as connected with a typhous diathesis or fever, typhoid pneumonia; 

* See Table p. 790. 



854 THE PRINCIPAL DISEASES OF THE 

third, as complicated with autumnal fever, or its occurring soon after that 
fever, bilious pneumonia. These varieties we shall study separately, begin- 
ning with the simple. 

SECTION II. 

DIAGNOSIS AND LESIONS OF PNEUMONIA. 

I. Symptoms. — It is not necessary that I should go into a minute and 
extended symptomatology of this disease, so familiar to all our physicians, 
so uniform in its phenomena, and so carefully described in nearly the same 
words in all our books. From the foundation of the Laennec school down 
to the present time this has been one of the thoracic maladies which has 
received most attention* and been most successfully studied. As far as I 
have been able to compare its symptoms as seen in this country with the 
descriptions of European writers, they are substantially the same. 

When pneumonia occurs in an endemio-epidemic, the attack is generally 
sudden, and the full development, constitutional and topical, correspondingly 
rapid. A severe and protracted rigor, or a chill bordering on an ague-shake 
with a feeling of pulmonary embarrassment, is followed by fever and aug- 
mentation of thoracic difficulty. But sporadic cases often, not always, 
begin much more insidiously ; and it may be many days before they are sub- 
mitted to the notice of the physician. Throughout that time the patient 
may have some catarrhal symptoms, or they being absent, he will have a 
dry and rather smothered cough, a sense of fulness or constriction in the 
chest, with some difficulty in making a deep inspiration ; more or less dull 
pain ; a pallid or dusky visage, and a reduction of surface heat. As to the 
state of the pulse in these cases, I find in an unpublished little paper, read 
before a medical society forty years ago, the following sentence : " The pulse 
at the commencement is moderate ; now and then it is even below the stand- 
ard of health both in force and fulness : at other times it is small, but 
somewhat tense ; in some cases it is as slow as in health, but generally it is 
too frequent." Subsequent observation has not modified this statement. 
Left to itself, such a case at length presents a slight chilliness, after which 
the development of the fever begins ; but if the patient be bled reaction is 
apt to come on without the occurrence of shivering. Until the access of the 
hot stage in both modes of attack, as the drawn blood shows no buff, and 
the symptoms are not phlogistic, the affected lung is, I suppose, in a state of 
passive congestion or simple hyperaemia, but thenceforward there is active 
hypersemia or inflammation. 

The symptoms are now rapidly ingravescent. The cough increases, but 
is seldom deep and loud ; the breathing is short and frequent ; the sense of 
weight or constriction in the chest becomes greater; more or less dull and 
deep-seated pain is felt; mucous expectoration often mingled with striae of 
blood begins, and soon changes to greater viscidity, with the intimate 



INTERIOR VALLEY OF NORTH AMERICA. 855 

admixture of the coloring matter of the blood, which gives it a prune-juice, 
brick-dust, or ochrey appearance ; the tongue shows the erect white fur of 
the phlegmasiae, and headache supervenes ; but the stomach and bowels are 
not in general disturbed. In this state the pulse may be various in character. 
The cases are not a few in which (until after bloodletting) it continues small 
and somewhat interrupted or hesitating, though preternaturally frequent ; 
but otherwise (and almost invariably after the first or second bleeding), it be- 
comes full and tense. When this does not happen, the inflammatory conges- 
tion is of such extent as seriously to impair the transmitting function of the 
lung; and the danger is correspondingly great. 

The symptoms now continue, with no other modification than that of 
increased intensity. If severe from the beginning, the attack may run on 
to a fatal termination in five or seven days ; but in milder cases the termina- 
tion in death will take place after the first or even second week. Advancing 
to such an issue, the pulse loses its force and fulness, but increases in fre- 
quency and unsteadiness ; the sputa become more tenacious, and instead of 
increasing, often diminish in quantity ; the breathing becomes shorter and 
more rapid j the difficulty of expanding the lungs augments ; the patient 
feels a necessity of having his head and shoulders raised, and asks for a free 
supply of fresh and cool air ; his countenance evinces extreme anxiety ; his 
face is sometimes pallid, but oftener dingy; and his lips and nails assume 
the livid or smoky hue, indicative of defective aeration of the blood. It is 
unnecessary to follow these signs of impending dissolution any further; 
and I turn back to speak of a symptom which has been passed over. It is 
well known that fever from any cause whatever, will in some persons pro- 
duce delirium. This is a frequent occurrence in pneumonia, and has been 
ascribed to the state of the blood, of which I have just spoken. It is, how- 
ever, more properly ascribed to the intensity of the fever, or to sympathy 
of the brain with the lungs, for it occurs long before the exhibition of une- 
quivocal signs of carbonated blood may arise, in mere lobar or limited 
inflammation, if the fever be intense ; and, finally, there is no evidence that 
defectively aerated blood produces the active delirium so often present in 
this malady. That state of the blood may, however, modify the delirium by 
superinducing coma, and to it we may ascribe the benumbed and drowsy 
condition of the patient so portentous in the latter stages of this malady. 

Thus strongly marked in its symptomatic history, I cannot see how any 
one can be mistaken in the diagnosis of pneumonia, any more than of hepa- 
titis or gastritis. Pathological anatomy has demonstrated that when these 
symptoms are present, the parenchyma of the lung is inflamed ; and it is 
by their guidance alone that an immense majority of our physicians are 
conducted to the conclusion on which their practice rests. 

II. Physical Signs. — Notwithstanding the sufficiency of the symp- 
toms for a correct diagnosis in ordinary and well-developed cases, we are 
by no means to neglect or undervalue the signs afforded by auscultation 



856 THE PRINCIPAL DISEASES OP THE 

and percussion ) the knowledge of which, in this and other maladies of the 
chest, constitutes one of the greatest triumphs of medicine, and, in some 
cases of disease, one of the most valuable. Yet the physical signs, in a 
certain sense, but reveal to us through the ear, during life, what the scalpel 
will disclose to the eye after death. They largely depend on derangements 
of structure, and, in a much more limited degree, give indication of the 
pathological actions from which those derangements result, and which it 
is the object of treatment to avert. 

To reason against the practical value of percussion and auscultation, ah 
tgnorantid, would be manifestly absurd. Yet when writing in and for an 
age and country, where a most imperfect knowledge of these signs exist, 
it is agreeable to believe that our practice may, in the majority of cases, be 
safely guided by the symptoms. The degree of inflammatory action is, in 
every case, that which must determine the amount of treatment which is 
applicable to all cases ; and this is indicated by the state of the pulse, of 
the drawn blood, of the skin and the tongue, taken in connection with the 
stricture, cough, and expectorated mucus. Percussion and auscultation tell 
us of the effects produced by the inflammation, and may suggest a great 
deal on the prognosis of the case, and on what may be called the secondary 
treatment. It still remains, however, as our great duty, to prevent the 
lesions of structure by subduing the inflammation, and this, I am disposed 
to believe, is, on the whole, as successfully accomplished by the physicians of 
the Interior Valley as by those in the great cities of the Atlantic States or 
of Europe.* 

In the early period of pneumonia the resonance of the chest under per- 
cussion is not much reduced, for the inflamed part is still permeated by the 
atmosphere, and when the inflammation is deeply seated it may be almost 
unimpaired, and yet great destruction of tissue may be going on. An early 
loss of resonance is evidence that the inflammation occupies a more exterior 
portion of the organ. The topographical area of the dulness shows the 
extent of the inflammation ; over the centre of which, where the air is 
entirely excluded, it is most perfect. As we pass from what may be called 

* The fundamental cause of defective skill in percussion and auscultation is the want of a familiar 
acquaintance with the natural and healthy sounds of the chest and lungs : the study of which by per- 
sonal experiment and observation on all ages, sexes, and classes of persons, should be enforced in the 
office of thoprivate preceptor : for it cannot be prosecuted either in the university or hospital. To come 
up to the study of the pathological or abnormal sounds without this knowledge of the physiological, 
is as absurd as to study the hyperinosis of the blood in pneumonia, or its hypinosis in typhous fever 
or scorbutus, without having first acquired a knowledge of its proximate elements in health. Yet the 
few who have an opportunity, during their two short courses of lectures, of examining dispensary or 
hospital patients, generally take up the pleximeter and the stethoscope, in utter igorance, as far as 
observation is concerned, of the normal thoracic and pulmonary sounds; and of course the know- 
ledge they acquire is superficial, inaccurate, and unreliable. The teaching of auscultation and percus- 
sion has very unfortunate] y been made a specialty, which has suggested to thousands that it cannot 
be prosecuted without the aid of a teacher. I know of nothing in our science, in which a man can be 
more sucessfully his own teacher. Any one of the numerous admirable works on these subjects with 
his own fingers and ears, even unarmed with pleximeter or stethoscope, will enable any young physi- 
cian, in a brief period of time, to become aufait in these means of thoracic diagnosis. 



INTERIOR VALLEY OF NORTH AMERICA. 857 

the zero of hollow sound, the resonance increases in all directions, for the 
obstruction to the admission of air diminishes ; and entirely beyond the in- 
flamed part, the sound may even be unnaturally loud from abnormal distension 
of the air-cells, to make up for the obliteration of those which are inflamed. 
The return of resonance, always gradually of course, indicates resolution of 
the inflammation, and presages recovery. But this restoration follows on 
rather than proceeds, pari passu, with the abatement of the inflammation, 
which never fails to manifest itself by abatement in the urgent symptoms. 
It may even be some time before those organic changes have occurred, by 
vascular contraction, interstitial absorption, and bronchial secretion, that 
will render the inflamed part re-permeable by the air ; and in some cases 
they never occur. Thus, it is not uncommon to see individuals who have 
recovered from pneumonia, — but of course remaining infirm — have obtuse- 
ness or flatness of sound for several months after the attack ; and I know 
a gentleman at this time whose side has continued in that condition for 
more than three years. In the spring and summer of 1843, when travelling 
in the southern part of the Valley, after pneumonia, especially among the 
blacks, had been unusually prevalent in the latter part of winter, I saw 
many going about with a large portion of one lung so hepatized as to give 
out a perfectly flat sound on percussion. 

In the beginning of pneumonia, when there is nothing but sanguineous 
engorgement of the lung, producing doubtless a certain degree of compres- 
sion of the smaller bronchial tubes and the air-cells, but not destroying 
their permeability, little reduction of resonance, as we have seen, exists, and 
auscultation still discloses the natural murmur ; but when inflammation or 
active hyperemia supervenes, dulness of sound begins. This implies dimi- 
nution of permeability, and is the effect of secretion into those extremities 
of the respiratory tube. At first the secretion is unadhesive mucus, often 
streaked with blood, and when the stethoscope is applied, more or less of 
bronchial rhonchus is heard. 

Of course, but little is known of the anatomy of the lung in this stage of 
the disease, but from analogy, and from the appearance of the congested 
parts around the seat of inflammation when, at a more advanced stage, it 
has proved fatal, we may infer that if examined it would show great en- 
gorgement of blood, with frothy mucus and serum, which might be squeezed 
and washed out; that it would crepitate on pressure; swim in water, and 
when deprived as far as possible of blood, could be inflated. In short its 
structure would be unimpaired. 

But the exudation of lymph mingled with the mucus speedily commences, 
and is but slowly expectorated. The admission of air is now more limited, 
and the dulness of course increases. At the same time the passage of air 
through the minute tubes leading to the vesicles and its entrance into them, 
generates a new sound, which gradually replaces the respiratory murmur. 
This has been ascribed to two causes, the secretion of the sides of the tubes, 



858 THE PRINCIPAL DISEASES OF THE 

adhering by the viscid or fibrinous mucus, and the formation and explosion 
of minute bubbles in the lobules. Probably both modes concur in producing 
the crepitation characteristic of the exudative stage of pneumonia, and which 
has been compared to the deflagration of a salt, the rubbing of a lock of dry 
hair, and to many other sounds. To the production of this sound a small 
amount of admitted air is sufficient, and hence there is simultaneously with 
it increase of dulness under percussion. Its rise is progressive, and as it 
advances, the natural vesicular murmur declines till it becomes extinct, and 
the fine crepitus alone is heard. But in the fullest development, the sur- 
rounding unengorged parts may and generally do emit a louder respiratory 
murmur than in health, from having a greater duty to perform. The lym- 
phatic or exudative stage is now completely established, and is characterized 
as we see by flatness of sound, a central crepitation, and a surrounding 
puerile respiration ) physical signs which harmonize with the symptoms of 
intense inflammation and phlogistic fever which are then present. The in- 
flammation is now at its acme. A brief period may be sufficient to fill 
up all the inflamed vesicles and the small tubes of which they are the bul- 
bous terminations, when of course the crepitation ceases ; but this does not 
indicate greater intensity of inflammation, but only its prolongation. The 
transmitted bronchial respiration now succeeds the extinct crepitus, and in 
this condition from the combined influence of retarded transmission of blood 
from the right to the left side of the heart, defective aeration of that 
which passes through, and a lesion of innervation, the patient often dies. 
Examined after death, the lung refuses to collapse, does not crepitate, sinks 
in water, will not give out more than a part of its blood under pressure and 
washing, is easily torn, and exhibits a smaller granular aspect from the 
vesicles being distended with fibrinous mucus. There is also evidence of 
the secretion of coagulating lymph into the areolar tissue, which moreover 
shows spots of ecchymosis. This is the state of recent hepatization. Al- 
though the lung may have reached this, the necessary condition of violent 
inflammation in that structure, the disease is still amenable to treatment. 
An abatement of the inflammation, always indicated by the symptoms, is 
accompanied by decrease of congestion, and absorption of the serous portion 
of the lymph effused into the areolar tissue. This sets free such vesicles as 
were not filled with muco-lymphatic secretion, and air begins to enter them ; 
at the same time the secretion into the vesicles and smaller tubes of a less 
adhesive product — the natural sero-mucous fluid — detaches and dilutes their 
viscid contents, and by expectoration they begin to empty and the air re- 
enters them. Thus a reproduction of crepitation and a diminution of bron- 
chial respiration ensue. The latter soon ceases entirely, and the former is 
replaced by the respiratory murmur, which, however, is in some cases for a 
while obscured by the bronchial mucous rhonchus attendant on the copious 
expectoration. It is scarcely necessary to add that with the return of nor- 
mal respiration the resonance of the lung is gradually restored; or that a 



INTERIOR VALLEY OF NORTH AMERICA. 859 

signal abatement of the symptoms of inflammatory orgasm actually precedes 
the favorable change in the physical signs. 

No inflammation reaches the stage to which we have followed pneumonia 
without the secretion of pus ; which, of course, begins in the central or 
focal point, but lymphization does not cease as suppuration comes on — it 
only abates. Neither the physical signs nor the symptoms inform us that 
suppuration is going on. The mere lapse of time, should the case prove 
fatal, would justify the anticipation of finding pus after death. When 
sputa through the different stages of the inflammation shall be examined 
by the microscope, pus corpuscles will doubtless be detected, for the smaller 
bronchial tubes are likely to secrete that fluid. The expectoration may now 
become more copious, as the pus may contribute to the detachment and 
softening of the adhesive contents of the air vesicles, and with this will 
arise a mucous or even gurgling rhonchus. To what extent suppuration of 
the lung may take place, and still the patient recover, is not known. In 
general, the pus is diffused, as in the case of phlegmonous erysipelas of the 
extremities. This must not be ascribed to a want of the coagulating lymph 
necessary to the construction of restraining walls, but to the open or areolar 
structure into which it is poured out. In the compact texture of the liver 
such diffusion cannot take place, and it accumulates into an abscess. 
Such an accumulation in the lungs is rare. My own limited experience 
coincides with that of the great pathologists. I have seen but a single case 
after death. It was in the middle lobe of the right lung, and confined by 
the union of the pleura of the organ to that of the side. Professor Gross 
has seen but one case, save that of many small lobular abscesses in the lung 
of a child.* Yet I have had several apparent instances of vomica, some of 
which were cured. The symptoms of pneumonia, not pleurisy, preceded 
the copious purulent expectoration. One case was remarkable in this, that 
with the symptoms of pneumonia, there was no pain in the chest, but below 
the cartilages and diaphragm on the left side, in the splenic region. The 
patient had not labored under any previous disease of the spleen. Great 
dyspnoea and intolerance of recumbency existed for some time before the 
sudden expectoration of a large quantity of pus, under which the patient 
sunk. The absence of pleuritic symptoms pointed to pneumonia. No post- 
mortem inspection was permitted. This case and most of those I have seen 
followed on the great influenza of 1807, a disease more likely to excite or 
predispose to pneumonia than pleurisy. In the diagnosis of such cases, the 
physical signs, not then understood in this country, would have been of 
much value. 

III. The differential diagnosis and complications of pneumonia deserve 
attention. It may be distinguished from bronchitis by the fixed position 
of the pain ; by the occurrence of rust-colored sputa instead of transparent 
mucus streaked with blood ; by the later coming on of expectoration ; the 

* El. Path. Anat. p. 435. 



860 THE PRINCIPAL DISEASES OF THE 

dulness of sound under percussion, and by the auscultic sounds which 
have been enumerated, instead of the ordinary mucous rhonchus of bron- 
chitis. 

I have several times seen, in post-mortem inspections, the evidence that 
pericardial inflammation may extend to the parenchyma of the lung. In 
such cases the signs and symptoms of the former, to be hereafter men- 
tioned, will have preceded those of the latter, which will consist in the 
characteristic sputa, with greater cough and dyspnoea than attend pericar- 
ditis ; in more extended dulness under percussion, and in the development 
of a crepitating rhonchus, the perception of which, however, is almost pre- 
vented by the loud sounds of the heart. 

Pneumonia in the base of the right lung may be confounded with hepa- 
titis, especially when this is seated in the convexity of the liver. The 
absence of the characteristic expectoration, with the ability to make a deep 
and prolonged inspiration, and the presence of bilious symptoms and in 
some cases irritability of the stomach, seldom attendant on pneumonia, are 
negative and positive symptoms on which much reliance may be placed. 
Percussion is of little value, except when the inflammation ascends beyond 
the region rendered obtuse by the position of the liver, which however 
varies in different persons. Auscultation is here of great value. The pre- 
sence of a normal vesicular murmur shows the integrity of the lung. Yet, 
in the progress of the hepatic inflammation, the lung may become involved, 
and this will be disclosed by the stethoscope, when we could not know it in 
any other way. 

In many parts of the Interior Valley enlarged spleens are common, and 
the organ in this condition is liable to inflammation. The method of dis- 
tinguishing this from pneumonia has been already pointed out, and need 
not be repeated here.* I have seen but a single post-mortem evidence of 
the extension of inflammation from the lung to the spleen. It had per- 
meated the diaphragm, which adhered to both. Suppurative inflammations 
of the spleen more seldom take the direction of the lung than those of the 
liver. 

SECTION III. 

TREATMENT OF PNEUMONIA. 

I. The treatment of few violent and dangerous diseases is so simple as 
that of pneumonia. A pure inflammation, often very extensive, of a great 
and vital organ, it demands an early and energetic antiphlogistic method, 
the agencies of which are more potent than numerous, and require intre- 
pidity on the part of the physician, whose great merit in the treatment of 
many other diseases may lie in his cautious circumspection or skilful for- 
bearance. The danger in this disease is proportionate to three conditions, 

* See p. 157. 



INTERIOR VALLEY OF NORTH AMERICA. 861 

first, the intensity of the phlogistic diathesis; second, the extent of the 
inflammation, especially its existence in both lungs ; third, its approach to 
the apex of the lung or the base of the heart. The first of these may be 
determined by the general symptoms, the last two by the physical signs. 
Before commencing the treatment we must recollect what I have not yet 
mentioned, that in the aged, infirm, or leucophlegmatic, the lung may be 
deeply engorged, with but little development of inflammatory orgasm ; and 
such cases must, in general points of treatment, be excepted from the 
therapeutic rules applicable to acute inflammation. They constitute a part, 
at least, of what the older writers called peripneumonia notha. Having 
eliminated these, we have to combat a simple, acute idiopathic phlegmasia, 
the means of doing which I proceed to consider seriatim. 

II. Bloodletting. — We may deduce the necessity for copious blood- 
letting in this disease from several premises. First. The tone of inflamma- 
tory action, as indicated by the symptoms and the remarkable hyperinosis 
of the drawn blood. Second. The necessity that all the blood of the body 
should pass through the lungs in a given time. If the left ventricle in 
health throw out two ounces at each contraction and repeat it every second, 
twenty-two pounds and a half, a quantity equal perhaps to the whole, must 
pass through the lungs every three minutes. But if the contractions be 
one hundred in a minute, and the heart should then throw out but an ounce 
and a half at once, the whole quantity will be required to pass from the 
right to the left side in less than two minutes and a half, a portion of the 
transmitting tubes being at the same time incapable of performing their 
functions ; the difficulties under which this may place the right side of the 
heart and its venous system cannot be misconceived. Third. The vena 
azygos, which returns the blood carried into the lungs by the bronchial or 
nutrient arteries, opens so near the right side of the heart, that this accu- 
mulation of blood cannot fail to retard the discharge from that vein, and 
still further to increase the engorgement of the inflamed organ ; while the 
exit of the blood of the heart by the coronary veins is equally retarded, 
producing in the parietes of that organ a congestion which, with the conti- 
nued restriction of the right auricle and ventricle, may perhaps in part 
explain some of its anomalous movements in pneumonia, and especially its 
liberated action after free bloodletting. Fourth. The proximity of the en- 
gorged and inflamed capillaries to the heart, wjiich is closer than that of 
any other portion of the vascular system except the coronary arteries. 
Thus it happens that when the capillaries which connect the pulmonary 
artery with the pulmonary veins are the seat of obstruction and hyperemia, 
with the active morbid function of inflammation, the violent vis a tergo of 
the blood from the right ventricle through the short pulmonary artery, 
cannot fail to cause a rapid augmentation of the inflammation. Fifth. The 
readiness with which the lungs undergo lesions of structure. This results 
from the absence of a compact parenchyma, like that of the liver or kidney. 



862 THE PRINCIPAL DISEASES OF THE 

Composed of two classes of vessels carrying blood into them, and two classes 
carrying blood out of them, of a system of tubes carrying the atmosphere 
inward and outward, and a system of cellules which receive, retain, and 
give it out, the whole connected with areolar tissue so loose and elastic as 
to admit of great expansion and contraction, free surface is the great 
anatomical characteristic of this organ. Surface is present everywhere — 
solid parenchyma nowhere.* Such a structure may rapidly destroy itself 
with the products of inflammation. Sixth. The fatal effects of this disor- 
ganization upon the whole system, through the interrupted aeration of the 
blood and its effects on the nervous system. 

Stronger reasons than these cannot be found in the inflammation of any 
other organ, for the early and copious detraction of blood. 

In the forming stage of some inflammations it may not be proper to bleed, 
but referring, as we have done to the position of the lungs, in the highway 
of the whole circulation ; seeing, indeed, that, for a certain distance, they 
constitute that way, we cannot doubt the propriety of immediately lessening 
the quantity of blood to be transmitted along it, when we find any portion 
of it obstructed ; and hence, venesection is proper even before the develop- 
ment of inflammatory orgasm in the solids, or a state of hyperinosis in the 
blood. As I have already said, the blood drawn in this stage generally 
shows no buff, yet the thoracic weight and constriction are abated by it, and 
the medicines which may be administered produce more decided effects than 
when they are given ante venesecttonem. After such a bleeding the heart gene- 
rally acts with greater force and frequency ; and the second, or, at most, the 
third, bleeding shows an abounding hyperinosis. Thus, although bloodlet- 
ting will not, as a matter of course, prevent the development of inflamma- 
tion ; it must contribute to its limitation in extent and intensity, and con- 
sequently to the preservation of the lungs from disorganization. 

But the physician, in general, is not consulted till actual inflammation 
has been developed, when the first-drawn blood is found buffy : yet the 
second-drawn, is generally more so, and the third, in many cases more buffy 
still. This, however, should not be regarded as conclusive evidence of 
increasing inflammation (though such may be the fact), but of a rapid dimi- 
nution of the red corpuscles, giving a greater comparative quantity of 
fibrine. Aud this explanation suggests that we are not to continue the repe- 
tition of bloodletting as long as the buffy coat appears, for in doing so, we 
may impoverish the blood, and generate constitutional irritation. From the 
direct hydraulic power of the right side of the heart, exerted through the 
pulmonary artery, and of the left side, through the bronchial arteries, over 
the lungs, it is necessary (always safe) to carry our first and second bleed- 
ings so far as to enfeeble that organ, and by reducing its mechanical force 
to save the lungs from the injection to which they are exposed. The first 
abstraction should produce syncope, or the nearest possible approach to it, 

* The universe has its centre everywhere — its circumference nowhere. 



INTERIOR VALLEY OP NORTH AMERICA. 863 

and the second, if the heart should recover its power, should be carried to 
the verge of fainting, but not further. This bleeding may be practised in 
six, eight, or twelve hours, or not till the next day, according to circum- 
stances, the import of which must be interpreted by the physician in each 
case. In cases of uncommon violence, occurring suddenly in persons of 
vigorous constitution, the third bleeding may sometimes be within or not 
beyond the first twenty-four hours after fever is well established. The 
number of bleedings cannot be brought under any general formula. The 
greater number of cases do not, I think, demand more than three, provided 
they be carried to the point I have indicated ; but a far more copious ab- 
straction is sometimes required. Thus, I have repeatedly found six or seven 
bleedings, ranging from thirty-two down to sixteen ounces, as imperatively 
demanded as two bleedings in other cases. After the third bleeding, how- 
ever, the physician should be on the lookout for nervous or constitutional 
irritation, the signs of which should arrest the further use of the lancet. 
This induced affection not unfrequently manifests itself by a sense of pul- 
monary oppression, which may be interpreted as evidence of increasing 
inflammation, and much injury may be done by the further venesection 
which it suggests ; but I must speak of it hereafter, and have only intro- 
duced it here as the evidence that the lancet should be laid aside. 

It not unfrequently happens in country practice, that the physician is not 
called in till four or five days or even' longer, after the disease is fully 
formed ; and the question then comes up as to the advantage or safety of 
bleeding. I cannot hesitate a moment in saying that unless the patient be 
in articulo mortis, when venesection would be both useless and absurd, it 
should be employed. It cannot directly remove infiltrations of lymph and 
pus, but it can diminish the inflammation in parts where it is less advanced ; 
and the loss of blood not only favors the absorption of effusions into the 
areolar tissue, but increases the susceptibility of the system to whatever 
medicines may be administered. But such a bleeding should never be car- 
ried to syncope. In some of these cases, the smothered pulse becomes more 
vigorous after the bleeding, as when it is employed in the forming stage, 
and then a repetition will be found necessary. 

When pleurisy is complicated with pneumonia, cupping, after liberal vene- 
section, may be useful, but in pneumonia only, it is utterly inefficient, and 
by substituting it for venesection, much injury may be done, or rather per- 
mitted. 

III. After a first full bleeding, the next prescription should be an active, 
antimonial, emeto-cathartic. Jalap, calomel, and tartar emetic combined, 
do very well ; the powders of the latter two, with nitrate of potash, already 
recommended in the other phlegmasia, are valuable ; or a solution of emetic 
tartar, with sulphate of magnesia, may be preferred. The object is, while 
the system is yet in the relaxed condition which follows on a copious bleed- 
ing, to effect a thorough evacuation of the stomach and bowels. Vomiting 



864 THE PRINCIPAL DISEASES OP THE 

generally takes place if the bleeding have been carried far enough, and its 
effects on the inflamed lung are always beneficial. The purging not only 
removes matters which, retained in the bowels, would reactively increase 
the fever, and contribute to the production of delirium; but increased 
secretion and excretion from the alimentary canal, lowers the vascular 
excitement, and, to a certain degree, makes revulsion from the lungs. 
After the operation of one active cathartic, however, aperients only should 
be given; for continued purging is injurious. It wastes the strength of 
the patient without subduing the inflammation, and especially interferes 
with the restoration of the healthy secretions of the lungs, and the expecto- 
ration which finishes the cure. 

IV. There are three antiphlogistic or sedative alterants, which, in this 
inflammation, are of more value than the whole materia medica beside. They 
are calomel, tartar emetic, and digitalis. 

1. Calomel. — Essentially seated in the vesicular and areolar tissues of 
the lungs, pneumonia partakes freely of the character of serous or exuda- 
tive inflammation, to which experience shows calomel to be well adapted. 
At the beginning of this century, its administration in pneumonia was more 
constant and liberal than in latter years ; and I have so often seen the 
inflammation yield on the access of a mercurial impression, that I cannot 
doubt its beneficial effects. Still it was not always successful, and sometimes 
produced a harassing salivation. There was, at that time, a reason for its 
use, which, in many parts of our country, no longer exists — at least, to the 
same extent, that is, hepatic or bilious complications. Calomel alone was not, 
however, relied upon, but given alternately with the two other medicines 
which have been named; and the change of treatment which has occurred, 
consists in an abridgment of that medicine, an almost total discontinuance 
of the digitalis, and a great increase in the quantity of tartar emetic. 

2. Tartar Emetic with Tincture of Digitalis in Mucilage of Gum 
Arabic. — This, in former times, was my great reliance, and as far as my 
observation extended, the reliance of others. Half an ounce of the muci- 
lage, containing the sixth of a grain of tartar, and ten drops of the tincture, 
every two hours night and day, beginning after one bloodletting and one 
emeto-cathartic ; three or four, two, four, or six grain doses of calomel being 
interposed every twenty-four hours, and the venesection repeated when the 
state of the pulse demanded it, constituted the curative treatment. Occa- 
sional vomiting and almost continued nausea, were produced by the tartar, 
while the digitalis went on with less of sensible effect to work out its pecu- 
liar crippling effect on the heart. This was manifested by reduction of 
force, but still more by reduction of frequency, and production of intermis- 
sions in the contractions of that organ, which effects were, of course, the 
signal for leaving that medicine out of the compound, as they were in 
general the harbingers of recovery. It was during the employment of this 
in pneumonia that I had opportunities of observing that, if given to much 



INTERIOR VALLEY OF NORTH AMERICA. 865 

extent before bloodletting, it will increase the force and frequency of the 
heart's contractions, following in that respect the same law with opium. 

8. Tartar Emetic. — Since the Italian practice of giving this medicine in 
large doses has been introduced into the Interior Valley, calomel and the com- 
pound I have mentioned have been much less used than formerly, even the 
lancet has been less freely used. I have myself for many years adopted this 
practice, and can add my humble testimony to that of the great men of the pro- 
fession, who have borne witness to its efficacy. Yet I am not quite convinced 
that it possesses any advantage over the antimonial in minute doses, aided by 
or aiding calomel and digitalis. I invariably administer it in one-grain pills, 
every two, three or four hours; but in cases of high phlogistic diathesis give 
two at once. That tolerance of these largest doses, so generally observed by 
others, I have often seen, and, like them, have regarded its disappearance as 
evidence that the inflammation was conquered, or at least yielding. I have not 
seen gastritis produced by this practice ; but should fear it might arise if blood- 
letting were omitted or but sparingly employed, as* some physicians have pro- 
posed. There are cases, however, to which the weak solution, with tincture of 
digitalis, is better adapted. They are distinguished by the gastric irrita- 
bility and gastrodynia which sometimes follow on the administration of the 
grain pills, which should therefore be superseded by the solution, the tinc- 
ture of digitalis not exerting that kind of influence on the stomach. 

The three medicines we are considering concur in arresting pneumonia, 
but not by the #ame mode of action. They are not therapeutic equivalents. 
The calomel directs itself against the phlogistic diathesis, and also upon the 
sero-mucous, vesicular tissue of the lungs. Tartar is undoubtedly a seda- 
tive to the vascular system; but, like other emetic medicines, has a specific 
action on the lungs, reducing and altering the morbid action, while it 
restores the normal secretion of the vesicles, and contributes to the solution, 
detachment, and expectoration of their adhesive or fibrinous contents. 
Digitalis acts, I think, chiefly on the heart, to the end which has been 
already pointed out. 

V. There are other medicines which may be substituted for these ; but 
not, I apprehend, with advantage to the patient, though, in mild cases, they 
may be successful. The most important are ipecacuanha, lobelia, and 
squills. I shall not dwell upon them. The most important of the three is 
squills, which, combined with calomel, is a medicine of considerable power. 
A pill composed of two grains of each, administered every two hours, soon 
produces a deep antiphlogistic impression. The effect of squills on the 
heart is often manifested in great reduction of the frequency of its contrac- 
tions, while it promotes expectoration, and, atr the same time, that medicine, 
in my own hands, has. seemed to quicken the action of calomel on the 
salivary glands. 

VI. Of revulsives, the best is a large blister, followed by smaller ones 
vol. ii. 55 



866 THE PRINCIPAL DISEASES OF THE 

around the first. The thoracic oppression and stricture are frequently re- 
lieved thereby. To be efficacious it should not be applied till the force of 
the heart is brought down by venesection. In children the plaster should 
be removed as soon as the vesication begins, and a poultice applied. 

VII. Demulcents and diluents are proper throughout the whole attack. 
They may be slightly acidulated with one of the vegetable acids, or such a 
quantity of nitrate of potash dissolved in them as may be practicable with- 
out imparting an unpleasant taste. They seem to pass by endosmosis from 
the stomach to the vena portas, and are very soon thrown into the inflamed 
part, soothing it as tepid water soothes an external inflammation. I cannot 
say that the gums and acids accompany the water on this route ; but it 
seems quite certain that the nitrate of potash does, for it shows itself in the 
urine. 

VIII. In the advanced stages, or rather in the progress of pneumonia, 
when copious bleeding has been practised, and especially in men of a lym- 
phatic temperament, constitutional irritation, as we have seen, is sometimes 
developed. It co-exists with congestion of the lung ; but active inflamma- 
tion no longer exists. The pulse is frequent, but compressible. There is 
still cough, but with sparing expectoration. The crepitant rhonchus is gone 
or departing, and a mucous rattle is more or less present. The patient 
feels a heavy thoracic oppression with dyspnoea, sometimes sighs, is restless, 
anxious, and occasionally alarmed ; at the same time, the tongue, having 
lost its white fur, is either pale and flabby, or dry, and inciting in its half- 
detached and scattering patches of fur to dark color. In this condition the 
patient may rapidly sink and expire; but, happily, the remedies which the 
symptoms suggest seldom fail to remove them. These are gentle opiates, 
lac ammoniac, watery infusion of assafoetida, carbonate of ammonia, infusion 
of serpentaria, and wine whey. When the sense of sinking is very great, a 
sinapism to the epigastrium or dorsal spine often gives much relief. Two 
objects should be kept in view; to produce sleep, and excite perspiration, 
which being effected, recovery takes place. 



CHAPTER XVI. 

TYPHOID AND BILIOUS PNEUMONITIS. 



SECTION I. 

TYPHOID PNEUMONITIS. 



I. The frequency of pulmonary affection in the typhoid fevers is now 
admitted on the best of all authority, the pathological anatomist. Indeed 
if a new theorist should fix on the lungs as the original seat of fever, I know 



INTERIOR VALLEY OF NORTH AMERICA. 867 

not (if he were a skilful rhetorician), but he might make out as plausible a 
generalization- as that which designates the brain, the stomach, the ileum, 
or the spleen as the seat of the characteristic lesion. But regarding (as I do 
in the present state of our knowledge) the whole of these affections as second- 
ary local incidents or contingents, and not causes of the fevers in which 
they are found, they belong to the histories of those maladies. Yet there is a 
primary pulmonary affection connected with, but not arising from them, 
which is entitled to consideration under this head. It appears sporadically ; 
also as a sub-epidemic; and sometimes as a wide-spreading epidemic. 
These modes of occurrence are the same as those of the typhous fevers ; but 
we must not, therefore, conclude that the pulmonary affection has no other 
cause than the typhous diathesis. This state of the system is in fact gene- 
rally but a predisposition ; the ordinary causes of pneumonia acting upon it 
to excite the inflammation. But if the typhous diathesis be not the sole 
cause of this pneumonia, it is manifestly the cause of those peculiarities in 
the phenomena, treatment, aod lesions, which distinguish typhoid from 
simple, acute pneumonia. Whenever and wherever the typhous fevers pre- 
vail, all the phlegmasia are modified by the typhous diathesis. To this modi- 
fication in the case of one, pneumonia, we must now direct our attention. 

II. Pneumonia typhodes is characterized negatively by the absence, or com- 
parative absence of the signs and symptoms which express true phlogistic 
fever, with acute exudative inflammation ; yet both fever and inflammation 
are present j and the latter manifests itself at the beginning, or even earlier 
than the fever, precisely as in the simple acute variety; and not in the pro- 
gress of the fever, as in typhous, when it is secondary. The access, like that 
of typhous, is sometimes gradual and protracted, in other cases sudden, and 
accompanied by a severe chill, and a sunken state of the vital energies, out of 
which there springs a very imperfect reaction. The fur on the tongue is 
less white and abundant than in ordinary pneumonia ; the heat of the trunk 
is in excess, but that of the extremities often defective ; the pulse displays 
much variety in frequency and fulness, but is uniformly deficient in force, 
or becomes so after a single bleeding. The drawn blood forms a loose 
coagulum, and I have seen it form into separate ones, conjoined by shreds 
of fibrine, and when a buffy coat appears it is less firm, than in simple acute 
pneumonia. The intellectual functions are more or less confused and enfee- 
bled at an early period ; and coma with subsultus tendinum ere long mani- 
fest themselves. The pulmonary embarrassment is very great ; consisting 
of dyspnoea, cough, sense of fulness and constriction, without pain, except 
where there is extension of the disease to the pleura, and even then it is 
seldom sharp. 

A case of this kind, unaccompanied by the pulmonary affection, would bo 
classed with the typhous fevers ; and the same amount of pulmonary affec- 
tion, in the absence of all constitutional lesion, would identify it with the 
acute phlegmasiae. 



868 THE PRINCIPAL DISEASES OP THE 

These views suggest two great sources of danger, which place this affec- 
tion among the most formidable we are called upon to treat. The constitu- 
tional danger is nearly identical with that in typhous, the local with that in 
ordinary pneumonia; and, in general, the death of the patient is referable 
to the latter. This sinister termination may take place in two or three days 
— rarely earlier, in some cases much later. The fatal lesion of the lung or 
lungs consists largely in its congestion, assimilating it closely to the state 
of those organs when secondarily affected in typhous. The state of the 
constitution is unfavorable to the establishment of much acute inflammation ; 
but that very condition favors the congestion, which often asphyxiates the 
patient in the early stages of the disease. 



SECTION II. 

BILIOUS PNEUMONITIS. 

I. It is known to us all that our ordinary remittent autumnal or bilious 
fever awakens inflammation in various organs of the body, and among the 
rest, occasionally, in the lungs. It is not however to such instances that 
the names bilious pleurisy and bilious pneumonia are applied. Nor are. 
they applied in every case in which pneumonic inflammation is connected 
with disturbance of the biliary function, for the liver may be disturbed in 
its secretion and excretion by sympathy with some other organ, or by being 
involved in a general pathological lesion, such as fever or constitutional 
lesion. Still further, the phrase before us does not always indicate a disease 
attended with bilious symptoms, and so far its employment involves a sole- 
cism, yet perhaps we cannot find a better epithet, if we keep in mind the 
fact that bilious is the oldest and most generally received name for periodical 
autumnal fever ; and realize that the word bilious applied to pneumonitis, 
indicates some kind of connection of the latter with that form of fever. 

II. We must study the nature of that connection. I have already en- 
deavored to show* that our periodical fevers depend on one cause, which 
produces on the system a specific impression, that it establishes a peculiar 
diathesis, which, so to speak, is the soil whence the paroxysms spring, and 
enduring for a long time, favors their recurrence, under the influence of 
exciting causes, in the form of relapses. If it were established that the 
cause of this diathesis is some kind of malaria or miasm, this quasi morbid 
condition of the system might be denominated malarial; but in the present 
state of our knowledge it is better not to adopt a nomenclature which in- 
volves an hypothesis that might never be established. Yet I may for con- 
venience sometimes employ it as an arbitrary name for the diathesis pecu- 

* B. ii. P. i., on Autumnal Feyer. 



INTERIOR VALLEY OF NORTH AMERICA. 869 

liar to autumnal fever. The use of the word bilious is equally arbitrary, for 
in many of the cases now under consideration, no bilious symptoms may be 
present, yet their connection with the diathesis, which has been announced, 
is undeniable. 

III. Bilious or malarial pneumonitis expresses then an inflammation of 
some tissue of the lung, in an individual having the diathesis which has 
been mentioned ; and every case may be regarded as a pathological com- 
pound, the elements of which are that diathesis and a phlogistic diathesis 
or morbid impression made by climatic influence or any other agency, as for 
example the specific remote cause of influenza or measles, but the chief, are 
the variations of atmospheric temperature and humidity. We are familiar 
with the fact that such meteorological changes are a frequent cause of relapses, 
from December to June, in those who suffered from periodical fever in the 
previous August, September, and October, and may even excite first attacks 
in persons who were exposed to the cause of those fevers, but escaped during 
the latter months just named. Now the malady under consideration is a 
pulmonary inflammation, arising with such an attack, or, in a constitution 
predisposed to such an attack, and differs in its phenomena and required 
treatment, in the mode and degree that may be produced by such a diathesis 
as compared with a previously sound and healthy condition of the system. 

IV. In reaching a diagnosis of this malady it is not necessary to travel 
through the symptomatology of either autumnal fever or pneumonic inflam- 
mation, but simply to refer to some modifications of both. 

1. The signs of an intense phlogistic action are less conspicuous than in 
ordinary pneumonitis. The functional disturbance of the lungs may be 
quite as great as in the most acute inflammation, but it results largely from 
sanguineous engorgement, and retarded transmission of blood through the 
organ. 

2. The fever, instead of the continued type of the pulmonary phleg- 
masia occurring in those who have not received a malarial or autumnal 
fever impress, is subject to remissions even when most intense, while in 
numerous instances, it displays perfect quotidian and sometimes tertian 
intermissions. The pulmonary affection follows the same law. When it 
consists in well-developed inflammation, that condition does not, it is true, 
cease with the periodical abatement or cessation of the fever, but is greatly 
moderated to undergo revival with the fever; but when the inflammation is less 
intense, and the pulmonary lesion consists chiefly in passive congestion, it 
may so far disappear in the more or less perfect apyrexia, that the term in- 
termittent becomes almost as applicable to the local as the constitutional 
affection. 

3. Such is the derangement of the biliary function in autumnal fever, 
whether the attack be original, or occurring as a relapse, that in a large 
proportion of the cases now in our contemplation, bilious symptoms are 
decidedly present. In some, the secretion of healthy bile is excessive ; 



870 THE PRINCIPAL DISEASES OF THE 

the fur on the tongue assumes a dirty yellowish tint, there is a bitter taste 
in the secretions of the mouth, vomiting and purging of bile occur, and now 
and then eructations of that fluid. Its presence is also manifest in the 
urine, the serum of the drawn blood, the white of the eyes, the skin, and 
as I believe, but not on conclusive evidence, in the sputa from the bronchial 
tubes. In other cases the signs of a bilious deterioration of the blood are 
present, but there is no excretion of bile from the liver, which seems torpid, 
and by not pouring its bitter and alkaline fluid into the bowels, permits the 
occurrence of an exhausting diarrhoea, the discharges being watery, and so 
acrid as to excoriate the sphincter. 

It is unnecessary, I think, to go further into the diagnosis of bilious 
pneumonitis, except to inquire for a moment into its division into varieties. 
These of course are according to the seat of the inflammation, pneumonia, 
bronchitis, and pleurisy, in their relative frequency, occurring perhaps in the 
order of their enumeration, and hence I have placed the whole in connec- 
tion with pneumonia. As to the particular tissue affected, the determina- 
tion must be made by a resort to the differential diagnosis elsewhere pointed 
out. I am happy to believe, however, that in the absence of such diagnostic 
knowledge of a case, it may perhaps be as successfully treated, as if the special 
locality were conclusively ascertained. 

V. The views which have been taken of the pathology of bilious or ma- 
larial pneumonitis, harmonize perfectly with its topography. Below the 
latitude of thirty degrees, where the systems of the people for more than 
half the year are acted on by the cause of periodical fever, it is not uncom- 
mon, indeed nearly all the cases of pneumonitis which occur are of this 
kind, and the number would be greater still, if sudden and extreme varia- 
tions of temperature were as great below as above that parallel. In the 
southern zone the predominance of the malarial element is decided, the 
phlegmasial is less developed, and the condition of the lung is more conges- 
tive. About the thirty-third parallel, where the winter vicissitudes are more 
correspondent to the malarial impress, the disease is more prevalent, inflam- 
matory, and destructive to the lungs than further south. As we advance 
northwardly to the limits of autumnal fever the disease still prevails j and 
although cases occur as simply congestive as those in the extreme South, a 
larger number show symptoms of decided and dangerous inflammation, the 
malarial influence being abated, and the meteorological increased. Through- 
out the whole Valley, whenever we leave the low or paludal regions in which 
autumnal fever is rife, for the higher and drier where it is comparatively 
rare, and appears chiefly in a remittent form, the number of cases every- 
where lessens, and true phlogistic pneumonitis takes its place. In all 
the tracts infested with autumnal fever, moreover, there are individuals who 
never suffer from that fever, whose systems resist the action of the remote 
cause, and when such in the winter are attacked with pneumonitis, it may 
be as inflammatory as if they lived in places free from that form of fever, 



INTERIOR VALLEY OF NORTH AMERICA. 871 

and this reconciles the apparent discrepancies of practice pursued in different 
cases in the same locality, bringing them under the same rule with the diver- 
sities required in the same season in different localities. Thus it is in this 
as in many other diseases, that the study of etiology illuminates both our 
pathology and therapeutics. 

VI. The disease now under examination is one of the most formidable 
and fatal of our Valley. In the months of February and March it often 
has a kind of epidemic prevalence ; when it frequently carries off a greater 
number than all other maladies combined. It prevails more in its appro- 
priate localities, than simple acute pneumonitis prevails where no malarial 
diathesis exists. Thus, that condition of the system, like any other enfee- 
blement, predisposes to it, and gives to atmospheric change a greater effect 
than it would otherwise produce. Some of the most dangerous cases are the 
least inflammatory and most intermittent, presenting, in their phenomena 
and mode of termination, a great resemblance to malignant intermittents. 
Those in which the fever most affects a continuous type and the pulmonary 
affection is most decidedly inflammatory, are in general the least dangerous, 
because most amenable to treatment. In examining my notes, I find that I 
have conversed on this disease with more than a hundred and fifty physi- 
cians, scattered from the shores of the G-ulf of Mexico to those of the Great 
Lakes, and with their experience, and that published by others in the 
journals, taken in connection with my own in one of the middle latitudes, I 
shall proceed to speak of the metJwdus medendi which it demands. 

1. Bloodletting. — The extent to which venesection is required, or admis- 
sible in this malady, is inversely to the autumnal-fever diathesis. When 
this is slight, the true inflammatory diathesis is predominant, and free bleed- 
ing is demanded. The upward graduation is, of course, into that diathesis 
in its full development, and the treatment must correspond. Thus there 
are cases in which several venesections, all affording sizy blood, are found 
necessary. In many others, however, a single bloodletting is all that can 
be borne. In others, the feeble state of the circulation, or the decidedly 
intermittent character of the disease, forbids the use of the lancet altogether. 
This is not merely an a priori decision, but a deduction from practice, for a 
bloodletting has often been followed by a sinking of the powers of life, and 
increased engorgement of the lungs, with gradual and fatal asphyxia. In 
cases of this character, the blood is often free from buff, and the coagulum 
is large. When no, or no further venesection seems advisable, cupping has 
been very generally employed, and the majority of our physicians speak 
favorably of its effects. In connection with this remedy, I may refer to 
counter-irritation. Blisters to the chest, especially when the pleura is in- 
volved, often give great relief, and those of a large size should be used. 
They may be applied at an earlier period than in ordinary pneumonitis. 

2. Tartar Emetic, almost universally employed in the higher latitudes of 
the Valley, is either repudiated or very cautiously used in the lower. The 



872 THE PRINCIPAL DISEASES OP THE 

objection is, that it acts upon the bowels, and produces an exhausting watery 
diarrhoea. Such an effect is very pernicious ; but the very condition of the 
system which favors its production, admits, or even demands, the exhibi- 
tion of opium ; and by this medicine the bowels may generally be restrained. 
Sufficient of the tartar to act beneficently on the lungs, and sufficient opium 
to protect the bowels, constitute, then, a compound of much value in this 
disease, and may be employed in cases which do not permit the use of the 
lancet, or, after its use, with great hopes of benefit. Most of our physi- 
cians give it in eighth or sixth grain doses, but I prefer larger portions. In 
cases of great intestinal irritability, the tincture of digitalis may be advan- 
tageously conjoined with the other medicines, or with the wine of ipecac. ; 
or when the pulmonary affection is chiefly bronchial, with the tincture of 
lobelia inflata, or sanguinaria canadensis. An excellent vehicle for all 
these medicines is the decoction of snake-root. It is proper to add, that 
full vomiting is often employed in this malady with decided benefit ; but? 
in attempting it, regard must be had to that irritability which may carry the 
medicine rapidly into the bowels, and, by exciting them, do mischief, while 
the effect upon the stomach is lost. To prevent this ipecac, may be 
employed, but a solution of tartar emetic with laudanum answers the pur- 
pose perfectly well. 

3. Calomel is not so much indicated in this affection by the phlogistic 
diathesis, as by the involvement of the liver. As a specific promoter and 
regulator of the functions of that organ, it is required in almost every case. 
When the secretion of bile is defective, this medicine, combined with opium, 
soon restores it ; when costiveness is present, it constitutes our best cathartic • 
and, when the secretion of the liver is superabundant, it emulges the bile 
ducts, and, by changing the mode of action of the organ, at length diminishes 
the secretion ; or, at least, when laid aside, the secretion abates. As to 
copious purgation, not curative in simple acute pneumonitis, it is generally 
injurious in this variety; especially when effected by the cold, saline 
cathartics. 

4. Sulphate of Quinine. This is one of the most important, in many 
cases the most indispensable, remedies in this disease. By it, we meet the 
autumnal-fever diathesis. When this is well developed, as will be manifested 
by the low tone of inflammatory action, and by the tendency to, or actual 
occurrence of, intermissions, the quinine is strongly indicated, and without 
it the patient may perish. In more inflammatory cases, it is frequently 
required after a single bloodletting ; and, in the most inflammatory, 
demanding two or three bleedings, it is necessary to administer it. It 
should, in general, be combined with other medicines; and experience has 
shown, that it works well in conjunction with tartar emetic and opium ; and 
also (which is a more common mode) with calomel and opium. As to the 
quantity, it may rise from ten or twelve to twice that number of grains in 
the twenty-four hours ; and a good method is to give one-fourth the quan- 



INTERIOR VALLEY OF NORTH AMERICA. 873 

tity every six hours. In cases of an intermittent and ingravescent character, 
it may, however, be necessary to administer it in much larger quantities, 
combined with opium, a short time before the expected paroxysm, as for a 
malignant intermittent. 

When the course of treatment here pointed out fails, it may, I think, be 
assumed, that any other known to us, if, indeed, there be any other, would 
have been unsuccessful. 

VII. Development of Typhous Symptoms. — Almost all our phy- 
sicians practising where bilious pneumonitis prevails have met with cases 
(and the number, unfortunately, not a few) in which, at a stage somewhat 
advanced, coma, subsultus tendinum, low delirium, and a dry, fissured 
tongue have indicated the presence, to a greater or less extent, of typhous 
diathesis, engrafted as it were upon the malarial, which still manifests itself 
by the decided daily remissions of the fever. When we add to these an 
engorgement of the lung, we have as complex and formidable a combination 
of pathological conditions as the practice of medicine can present, and one 
which generally proves fatal. 

Bloodletting, even perhaps by cups, is, of course, not to be thought of; 
but blisters may be advantageously used. Purging is pernicious ; but full 
vomiting, not preceded by long-continued nausea, may at the same time 
arrest the lesion of innervation, and contribute to disembarrass the lungs. 
Calomel is no longer of much value. Tartarized antimony, however, may 
still be relied upon j but should be taken with a liberal quantity of opium, 
or the latter medicine may be conjoined with ipecac. The sulphate of 
quinine may still be employed in connection with these formula. Stimu- 
lating expectorants and sudorifics are now very important. The decoction 
of polygala seneka holding carbonate of ammonia in solution, with paregoric, 
is a suitable formula; the decoction of eupatorium jDerfoliatutn with sul- 
phate or acetate of morphia, constitutes another of good influence : another 
still is the lac ammoniac with assafoetida. The infusion of serpentaria, 
wine whey, and even hot whiskey and water, may be requisite. These things 
may be administered without much deference to the state of the lungs ; for 
if they be hepatized, death is in general inevitable, — if only engorged, they 
may be relieved by raising the excitement of the system. 

I shall reserve what might be said on chronic pneumonia and vomica till 
we come to chronic pleurisy. 



874 THE PRINCIPAL DISEASES OF THE 

CHAPTER XVII. 

PLEURISY, ACUTE AND CHRONIC— PLEURITIC CONSUMPTION. 



SECTION I. 

ACUTE PLEURISY. 

I. Diagnostic Symptoms and Signs. — Few diseases are more openly 
and unmistakably declared by their symptoms than acute pleurisy. Like 
pneumonia, it sometimes creeps on gradually, but not unconsciously, for the 
pain always warns the patient of its approach. In many instances this 
pain precedes the fever, and is at first mistaken for mere pleurodynia, or a 
neuralgic aching of the intercostal muscles, the pleura, or the periosteum of 
the ribs. In other cases, a severe chill ushers iu the disease, and the pain 
is not felt till it occurs, or even not till the febrile reaction takes place. 
This being established, the pulse becomes frequent, full, and tense, and 
changes its character but little till the inflammatory orgasm begins to abate. 
It is rarely or never smothered or strangulated, as in pneumonia, except 
when the inflammation dips into the parenchyma of the lung. The pain, 
generally seated near the middle of the side, is acute, and greatly aggra- 
vated by coughing, sneezing, or a deep inspiration, and hence the patient 
resists the whole. I have even seen them bind a napkin round the chest to 
arrest the ascent of the ribs. The cough is at first dry ; though the cause 
which produced the pleurisy may, at the same time, have generated bron- 
chial catarrh, when a mucous expectoration may exist from the beginning. 
However this may be,. it is not long before sputa of that kind are ejected; 
for the bronchial membrane takes on increased secretion, as if to relieve the 
sufferings of the pleura; and when the inflammation is seated in the pleura 
pulmonum, this result is, perhaps, in some degree attained. 

II. Physical Signs. — The symptoms which have been described can 
leave no doubt as to the existence of pleurisy ; but the physical signs are 
not to be neglected.* 

A respiration voluntarily restricted in its mechanical range, necessarily 

* Dr. C. J. B. Williams, in his classical work on the < : Physical Signs of Diseases of the Lungs and 
Pleura," after enumerating the symptoms, observes '• there are few practitioners who have not proved 
the fallacy of each of these symptoms, and, as we shall presently point out, the auscultator finds but 
uncertainty in them all.'' Now, it is certainly true that no one of the symptoms, any more than one of 
the physical signs, is sufficient ; but to say that there is uncertainty in the whole taken together, only 
shows how a most acute and vigorous mind may be fascinated by new truths into an injurious under- 
estimate of the old. I have said injurious, because he himself correctly informs us a little further on 
that the physical signs depend on effusions into the sac of the pleura. We are, then, to fold our arms 
and wait for the inflammation to produce its ravages, before we allow ourselves to adopt the very 
measures by which those ravages are to be prevented ! In regard to the second part of the quotation, 
it is worthy of remark, that the distinguished author did not point out how "the auscultator finds but 
uncertainty in them all," nor in any way attempt to demonstrate their uncertainty. 



INTERIOR VALLEY OF NORTH AMERICA. 875 

reduces the loudness and distinctness of the vesicular murmur of the affected 
side ; at the same time the sound under percussion may be normal. Early 
secretion takes place. When this is chiefly serous, it does not affect the 
respiratory sound, except by accumulation ; but when, from a high state of 
hyperinosis, there is an early effusion of lymph, the roughened surfaces of 
the two membranes, during inspiration and expiration, emit a rough rubbing 
or friction sound, the topographical extent of which marks the area of in- 
flammation. This sound disappears first in the lower part of the chest, 
because the subsiding serous secretion separates the pleurae from each other, 
and, for the same reason, it is heard latest in the upper part of the thorax, 
having in its gradual upward disappearance indicated the progressive rise 
of the effused fluid. The effect of this effusion is, of course, to reduce, and 
if it should be copious, to annihilate the respiratory murmur. But, if lost 
on the affected side, that murmur is loud and puerile over the other, as from 
the diminished movement of the ribs, and in part from the compression 
exercised by the effused fluid of the side affected, the other receives and dis- 
charges more than its usual quantity of air. At a certain stage of the effusion, 
the sound of the voice is heard shrill and lamb-like through the stethoscope. 
This, according to Laennec, arises from its passing through the effused fluid. 
It has also been said that the lung is compressed by the effusion, and thus 
made a better conductor of sound. The vocal resonance may, however, at 
all times be heard through the healthy lung, and in the stage of effusion 
when cegophony is most distinct, the amount of effusion seems too small to 
produce much compression of the lung. As the effusion increases, the 
sounds under percussion grow dull, and when it reaches a certain stage they 
are flat, with the loss of both cegophony and vesicular murmur, except over 
the root of the lung. A return of the friction sound, with increase of reso- 
nance under percussion, of course indicate that absorption of the effusion 
has taken place, and that a return of the respiratory murmur is at hand. 

III. Treatment. — After all that has been said on the treatment of acute 
pneumonia, it will not be necessary to dwell on that of acute pleurisy, for 
the measures are substantially the same in both, though they may need 
modification in each. The remarks made on venesection are applicable 
here ; but the loss of blood by cupping is more effective in this disease than 
in pneumonia, because the membrane lining the walls of the chest is the 
chief seat of inflammation, if we may judge from the effect of motion of the 
ribs. For the same reason blistering is now more effective, and when the 
inflammation precedes the fever, or is in the forming stage, a large blister 
followed by copious secretion sometimes arrests it. When the pulse, how- 
ever, has become highly excited, the counter-irritant will do no good until 
after copious venesection, when its effect is often decisive. Calomel is of greater 
benefit in this inflammation than in that seated in the vesicular or mucous 
texture of the lung ; and may be administered in small doses, amounting 
to twenty, thirty, or forty grains in the twenty-four hours, till the inflam- 



876 THE PRINCIPAL DISEASES OP THE 

mation ceases, or the mouth becomes affected. Its action, meantime, on 
the bowels, may render the exhibition of other cathartics unnecessary. Ke- 
peated purging is not curative in this affection ; but it constitutes a legiti- 
mate part of the antiphlogistic treatment j and in the earlier stages of the 
fever, it is necessary to effect full and complete evacuation of the existing 
contents of the alimentary canal. Tartar emetic is of less value than in 
pneumonia, yet as a general contra-stimulant it is useful, and may from the 
beginning be combined with calomel. The frequent participation of the 
parenchyma of the lung in the serous inflammation is another reason more- 
over for administering this medicine. When the calomel is laid aside, the 
antimonial may be continued with the tincture of digitalis, the action of 
which on the heart is no less necessary in this malady than in pneumonia. 
The tendency to coughing, and the increase of pain that function produces, 
suggest the use of opium, and after one or two copious bleedings it may in 
general be combined or alternated with the medicines just mentioned, to 
the great comfort of the patient. It should especially be brought to bear 
upon his system at night, when it may determine the action of the antimo- 
nial upon the skin. Early and copious expectoration is a favorable effect 
of our remedies, and should be promoted, as a mode of diminishing pulmo- 
nary congestion. It is unnecessary to say more on this subject. Whenever 
acute pleurisy is arrested, it is by the measures here briefly enumerated ; 
and by them, employed early and resolutely, it is in general cured. Yet, 
in some cases, they only moderate the inflammation, and with it all the 
violent symptoms, leaving enough of the former to produce serious and per- 
manent lesion of the pleura; and to these we must now give attention. 



SECTION II. 

CHRONIC PLEURISY. 

I. When acute pleurisy is entirely subdued, the physical signs are not 
always the same, for they must of necessity vary according to the stage 
which the disease has reached before its arrest. It might be during the 
first friction sound • or it might be after the separation of the sides of the 
pleurae, when no respiratory sound would be heard, and there would be 
dulness under percussion ; or it might be that while the patient was still 
under treatment, absorption of the serous element of the lymph had taken 
place, with reproduction of the friction found, foretelling the restoration of 
vesicular respiration. Now, when the inflammation is only brought down 
to a subacute or chronic grade, it generally happens that the resonance is 
dull and the respiratory murmur absent, both these negative conditions 
being most perfect in the lower part of the chest where the effused fluid 
settles. The same condition may be the effect of a pleurisy, mild or sub- 
acute from the beginning, one which has perhaps passed for mere pleuro- 



INTERIOR VALLEY OF NORTH AMERICA. 877 

dynia, for -which no physician has been consulted. When at length that 
is done, the signs indicating the stage of effusion just pointed out may be 
present. Thenceforward the two cases may follow the same law, although 
commencing with such great differences of intensity. 

II. Chronic inflammation of the pleura thus established, is commonly 
attended with a slight evening paroxysm of fever, which is often followed 
by some morning perspiration ; there is more or less of moderate pain in 
the affected side ; the cough is by no means urgent, and the expectoration 
is not copious ; a sense of weight or fulness exists in the affected side, the ribs 
of which rise and fall much less than those of the opposite. With these (to 
the patient) unalarming symptoms, the effusion of lymph, more or less rich 
in fibrine, and at length that of pus, are constantly going forward ; and now 
it is that percussion and auscultation afford assistance in diagnosis, although 
at the beginning of an acute attack they were by no means indispensable. 

The dulness gradually rises higher and higher up the side until not the 
least hollowness of sound can be heard except over the root of the lung. 
The voice and the respiratory murmur as heard through the stethoscope are 
of course annihilated, while the latter is universally puerile on the opposite 
side. With the increase of secretion the side bulges out, and the intercostal 
spaces widen. A deep inspiration introduces no air into that side, for the 
lung is compressed against the spine and cannot expand; in some cases the 
heart is forced over to the other side, and I have seen and felt its pulsations, 
as far on the' right as in health they are found on the left side. Great 
dyspnoea attends this condition, especially under exercise; a horizontal 
posture is dreaded, and the patient avoids lying on the sound side because 
it impedes the action of the ribs, and prevents the due inflation of the lung. 
Such is chronic pleurisy ; but there arise other phenomena, previous to the 
discussion of which it will be convenient to consider what can be done to 
relieve the patient from his present condition, and prevent any further diffi- 
culty. 

III. The treatment of chronic pleurisy has two objects in view '.first, the 
final arrest of the low inflammatory action; second, the absorption of the 
morbid secretions which it has poured into the pleural sac. 

1. In the early stages of this affection, repeated small bleedings, as of 
eight or ten ounces, are sometimes highly beneficial ; but more commonly, 
cupping is to be preferred. The cups should be successively applied over 
the whole side ; but more especially over the part which may be the seat of 
pain, or which evinces tenderness under pressure. They may be reapplied 
every other or every third day, and not laid aside till the symptoms which 
have just been named are removed, or it is seen that the contents are making 
their way to the surface by suppurative action. As a further external mea- 
sure, small blisters may be laid on various parts of the side, after the cup- 
ping is no longer employed; or it may be rubbed with antimonial ointment 
till pustules arise ; I have more confidence, however, in blistering. Of in- 



878 THE PRINCIPAL DISEASES OF THE 

ternal remedies calomel is in general use over our Valley. The seat of the 
inflammation in a serous membrane suggests its employment, and experience 
justifies the choice. The object is to produce a gentle and sustained mercu- 
rial action. Dr. Stokes justly regards this as the most important remedy at 
present known. A dilute solution of tartarized antimony with tincture of 
digitalis is also beneficial, to which at night, if the cough should be trouble- 
some, an opiate may be added. Throughout the treatment, the patient 
should take but little exercise; and live on a milk and bread or other bland 
diet. By this course of treatment many cases are arrested. 

2. Absorption is doubtless going on through the whole period of treat- 
ment, but secretion likewise continues, and the fulness of the pleural sac 
continues. But from the time the inflammation is arrested, absorption 
begins the work of reduction, and is promoted by the very means employed 
to bring down the inflammation, and by exciting expectoration and the uri- 
nary secretion. The squill is now valuable — might have been before — and 
may be advantageously combined with nitrate of potash. An ounce of the 
vinegar of squills, with ten grains of nitre, four times a day, is a good for- 
mula. Digitalis is also well adapted to this condition, and the infusion is 
perhaps better than the tincture. It may be advantageously combined with 
spirit of nitrous ether, an ounce of the former, and a drachm of the latter, 
three or four times a day, being the proper dose. Of course its effects on 
the pulse should be carefully noted, that it may not do injury to the heart. 
If the bowels should be torpid, the occasional administration of a hydro- 
gogue cathartic will be serviceable. ' To this end a pill composed of two 
grains of blue mass, and an eighth of a grain of elaterium, given every two 
or four hours, till copious discharges are produced, may be employed. The 
hydriodate of potash is likewise serviceable, and may be administered to the 
extent of ten grains, four or six times a day. When the powers of the 
system are low, the iodide syrup of iron will do good; and the administra- 
tion of equal parts of the bark and cream of tartar combined may also be 
given with advantage. 

Throughout the whole period a more generous diet than in the stage of 
secretion should be permitted; the side should be subjected to prolonged 
friction with a brush, or a rough hand, night and morning, aod the patient 
should be encouraged to take active exercise, so as both to excite absorption, 
and promote the expansion of the previously compressed, but now liberated 
lung. When it has not undergone an organic change, nor is confined by a 
dense covering of false membrane, its expansion proceeds pari passu with 
the absorption ; the bulging of the side diminishes, its resonance increases, 
the friction sound returns, and enduring for a while is succeeded by the 
natural respiratory murmur. When however the lung is incapable of ex- 
panding to its former dimensions, the ribs follow the diminution of the 
effused materials, and the side that was unnaturally convex, becomes finally 
flat or concave, and the vesicular murmur will remain absent or feeble. 
The result is cure with permanent deformity. 



INTERIOR VALLEY OF NORTH AMERICA. 879 



SECTION III. 

PLEURITIC CONSUMPTION. 

I. The cure of chronic pleurisy by resolution and absorption, is not 
always practicable. In some cases the malady is allowed insidiously to 
advance beyond the point at which the absorption of the effusion can be 
effected, the patient being unaware of his situation ; in others the physician, 
from inexcusable ignorance of the physical signs, remains equally unapprised 
of the organic mischief going on within, till his eyes are opened by the 
manifest bulging and loss of respiratory movement of the side, as observed 
without; in others the most judicious and timely treatment proves unavail- 
ing. There is a purulent tendency in the system which cannot be controlled ; 
and when the proportion of pus in the cavity becomes great, the absorption 
is much less active than while the bulk is chiefly serum with lymph. The 
purulent secretion having taken the place of the serous and plastic, the 
malady begins to assume a new aspect, and thenceforward may be denomi- 
nated pleuritic consumption. A phlegmasial fever is superseded by a hectic. 
Occasional rigors become at length concentrated into a morning or evening 
chill, followed by & paroxysm of fever, with a frequent, elastic but compres- 
sible pulse, succeeded by a morning perspiration, and gradual emaciation. 
This striking modification of the symptoms will cease when the pus is ab- 
sorbed, and the surfaces of the pleura have coalesced ; but such absorption 
is not always practicable, and the pleura is only emptied by the escape of 
its contents through the walls which contain them. When this escape is 
outward there is a gradual, obtuse pointing, somewhere between the ribs, 
and generally in the upper rather than the lower part of the chest. Very 
commonly, however, it is near the middle of the side where the pain of 
pleurisy is oftenest found. Sometimes there is a spontaneous rupture, but 
generally the firm texture of the thickened pleura, which may not give way 
even when absorption of the intercostal muscle is so complete as to bring 
the pleura into contact with the skin, renders the operation of paracentesis 
thoracis advisable. But the escape of the fluid may be inwards. Ulcera- 
tive absorption attacks the lung (establishing a topical pneumonia, which 
cannot, however, be detected by the physical signs), and a channel is exca- 
vated into one or more of the bronchial tubes, when a sudden and often pro- 
fuse expectoration of pus takes place. It is worthy of remark that while 
abscesses of the liver and spleen sometimes perforate the diaphragm, and 
discharge their contents by the bronchi, those of the pleura scarcely ever 
make their way downward. I have not met with a single case of this kind. 
When the pus does take this direction, the suppuration does not perforate 
the peritoneum, which would prove immediately fatal, but the pus insinuates 
itself behind that membrane, where it forms a kind of encysted, abdominal 



880 THE PRINCIPAL DISEASES OF THE. 

abscess, or descends along the muscles of the loins, and appears below in 
the form of a psoas abscess.* 

The escape of the pus (or rather its partial evacuation, which is all that 
takes place) is not followed by a cessation of the hectic fever, and when the 
discharge is by expectoration, the phenomena are so identical with those 
attendant on vomica or pulmonary abscess, that a discrimination may not 
always be found practicable. The previous history affords some aid, but the 
sudden return of resonance under percussion in the upper parts of the side, 
in the case of empyema, is a reliable sign ; to which may be added the 
greater area over which the metallic tinkling may be heard. Happily, how- 
ever, it is of no practical importance to decide whether the abscess be pleural 
or parenchymatous, the inflammation which produced it being simple; but 
it is of importance to distinguish both from tubercular abscess. Here, 
again, we may place much reliance on the previous historyof the case ; yet 
the physical signs are not without their value; they may, with a view to 
this differential diagnosis, be more conveniently studied when we come to 
speak of tubercular excavations. 

II. Considered in reference to the origin — from simple inflammation — 
the character of the secondary or hectic fever attendant on them, their re- 
quired treatment, and the mode in which the secretion of pus must be 
finally terminated, empyema and vomica may be united into one variety of 
pseudo-phthisis, or imitative consumption. In true phthisis the local affec- 
tion is maintained by the constitutional lesion ; but in this imitative form, 
the organic or topical derangement keeps up the constitutional, and what- 
ever interferes with its cure tends to give a fatal issue to the case. Now it 
is in the lung itself that we must look for this interference. Its free and 
full inflation is the condition most favorable to an obliteration of the puru- 
lent cavities, and the case is, ccctcris paribus, unfavorable in proportion to 
the reduced dilatability of that organ. Thus, in vomica, if there be hepa- 
tization of the lung around the purulent cavity, the approximation of its 
walls, in respiration, is less than if the surrounding vesicular tissue can be 
well filled ; and in empyema, the expansion of the lung is inversely to the 
degree in which it may be banded round with firm coagulating lymph. As 
this is great, the escape of pus by an external or an internal opening will 
be but small below the level of the orifice, but when the lung is not con- 
fined by false membrane, it expands from the moment the pus begins to 
flow out, and tends to bring its surface in contact with the pleura costalis, 
thus compelling the contents of the cavity to escape. When the discharge 
is by a bronchial tube, the same thing must happen ; and hence the pas- 
sage, of the air into the cavity of the pleura in this case, with the formation 
of pneumothorax, may be taken as an evidence that the lung cannot ex- 
pand as fast as the expansion of the chest in inspiration, for if it did the 
escape of pus at that moment would tend to prevent the ingress of air into 

* Atidral and Mohr, as quoted by Hasse. 



INTERIOR VALLEY OF NORTH AMERICA. 881 

the pleural sac. There are but two modes in which a cavity can be obli- 
terated, — by the reunion of its walls, when brought in contact, or by the 
reproduction of lost parts ; in both vomica and empyema I suppose the 
former mode of cure to occur. Not that close and universal adhesion in 
the case of empyema takes place, but that the contact of the pleural sur- 
faces promotes their union in part, and favors — on the remainder — the re- 
production of a free serous surface, with abatement of purulent secretion, 
the accomplishment of which completes the cure. 

III. The distinction which I have recognized between chronic pleurisy 
and pleuritic consumption is not founded on the extent of the effusion, but 
on its character. The sac of the pleura may be greatly distended with 
lymphy serum, containing at length more or less pus, as that secretion gra- 
dually appears in the mucus of chronic bronchitis, but this serum may be 
absorbed and no hectic fever supervene. It may happen, however, that the 
secretion of pus may be equal to the absorption of serum, and thus without 
an increase in the quantity of the contents of the cavity there may be a 
gradual change from the sero-lymphatic to the purulent. Until this chauge 
takes place, there is a good prospect of recovery by absorption, under the 
treatment pointed out in the preceding section. But when the pus comes 
to constitute the chief material in the pleural cavity, it is doubtful, the 
quantity being large, whether it is ever absorbed. Now, if this be the fact, 
as the long compression of the lung is highly injurious, the question may 
be asked whether the operation for empyema should not be performed much 
earlier than it is common to employ it ? If, under the measures known to 
excite the absorbents, hectic fever should begin to manifest itself, and no 
diminution of size in the affected side should be going on, should not the 
pus be drawn off? The reply should, I think, be in the affirmative. I 
would even carry this idea further, and suggest the propriety of creating 
an outlet for the effused fluid at a still earlier period, when the proportion 
of pus may yet be small. The sinister consequences of long-continued 
compression of the lung would thus be averted, while the difficulty of sub- 
duing the remains of inflammatory action would not, I suppose, be in- 
creased. In deciding on the operation, while as yet there is no pointing of 
the abscess, it is of course necessary to distinguish between empyema and 
general hepatization of the lung. The dulness under percussion is the 
same in both j but while in the former there is extinction of the respiratory 
sounds, in the latter, the solidified lung gives bronchial respiration. Yet 
if there should be neither bulging of the side nor displacement of the 
heart, and especially if the disease should be seated on the liver side, it 
may be prudent to perforate the walls of the side with the sounding-needle, 
and ascertain the existence of a fluid in the sac. 

"We do not, perhaps, know the reason why the spontaneous opening of 
the pleural abscess is generally in its upper part. It may be owing per- 

vol. ii. 56 



882 THE PRINCIPAL DISEASES OP THE 

haps to the early and long-continued sojourn of the heterologous secretion 
in the lower part of the cavity, which may reduce the vital activity of the 
walls, thoracic, pulmonary, and diaphragmatic, and this may be the reason 
why ulcerative absorption so seldom attacks the diaphragm. But from 
whatever cause the upper part of the side may be that through which a 
spontaneous discharge is effected, I see no reason for making the puncture 
there ; but, on the contrary, a reason for making it in the lower and pos- 
terior portion of the chest, that the contents may more fully escape. The 
alleged necessity of making it higher up, so as not to wound the diaphragm, 
deserves no consideration; for it is depressed, or at least so far separated 
from the side, by the condition which renders the operation necessary, as 
to be in no danger of being wounded. 

When the object is to draw off a sero-lymphatic accumulation, it is proper 
to make a valvular opening, and by appropriate dressings to prevent as 
far as possible the ingress of air at the time, and subsequently by effecting 
a reunion of the lips of the orifice, and to this end an abscess lancet or a 
flat trochar should be used. After one drawing off, the absorption may 
prove equal to the secretion, and a new accumulation be prevented. When 
pus is extensively and copiously secreted, however, the opening should not 
be closed, but the discharge allowed to continue till the secretion is arrested. 

The medical and hygienic treatment of empyema should be such as is 
demanded in other extensive suppurations attended with hectic fever. The 
medicines adapted to such a case are the cinchona bark, elixir of vitriol, 
opium, the iodide of iron, and the hydriodate of potash; with due attention 
to the state of the stomach, liver, and bowels, without which those medi- 
cines will not produce their wonted effects. Should diarrhcea supervene, it 
should be restrained -by the usual means. To limit the perspiration, the 
patient should lie on a mattress, and the whole surface of his body should 
be subjected to dry rubbing in the morning, after which it should be well 
protected if he go abroad. From the time when the pus begins to escape, 
whether internally or externally, by a natural or by an artificial orifice, 
efforts to expand the lung should be made with as much energy as possible. 
To this end, deep voluntary inspirations, sneezing, and, when the patient's 
strength permits it, locomotive efforts should be frequently made. As a 
means of restoring strength, he should take carriage or horseback exercise 
in the open air, and live on a nourishing diet, carefully avoiding, however, 
all gastric repletion. 

The effect of climate in this malady is in general quite obvious ; cold and 
moisture — all sudden changes indeed — are injurious, by re-awakening inflam- 
matory action, and therefore a mild and steady climate should, if the patient's 
circumstances permit it, be selected through the first cold weather that may 
follow on the discharge of pus. This is the disease known by the people 
under the name of "hasty" or "galloping" consumption, recoveries from 



INTERIOR VALLEY OF NORTH AMERICA. 883 

which have often taken place under the genial influence of a warm climate, 
and hence a fallacious association of ideas has been established in the public 
mind between such a climate and tne cure of tubercular consumption. 

Having travelled through the simple inflammations, both acute and chronic, 
of the respiratory apparatus, it only remains to study that which has a pecu- 
liar or specific pathological character, the disease which has just been named. 



CHAPTER XVIII. 



TUBERCULAR PNEUMONITIS OR PHTHISIS PULMONALIS. —ETIOLOGY 
AND PROPHYLAXIS. 

INTRODUCTION. 

It is impossible to approach the study of phthisis without a feeling of 
embarrassment, for we are met by two melancholy facts : first, its almost in- 
evitable mortality, and second, its great prevalence and apparent increase, 
notwithstanding the volumes which have been written on its causes, symp- 
toms, anatomical lesions, prevention, and cure. 

Every case of this disease presents us with two pathological elements, 
first, a peculiar lesion or diathesis of the general system; second, a hetero- 
logous deposit in the lungs, with suppurative inflammation. Judged by 
its progress and products the inflammation may be called peculiar or specific, 
yet this results entirely perhaps from its occurring in a tubercular diathesis. 
It is then to the constitutional lesion that we must look for what distin- 
guishes this affection of the lungs from those we have been studying. My 
own observations require me to adopt the opinion long entertained by the 
ablest physicians, that the constitutional lesions in scrofula and consump- 
tion are specifically and substantially the same, the difference in the pro- 
gressive phenomena of the two diseases, being chiefly the result of the 
deposit of tubercular matter in the different organs, although we may not 
be able to assign the reason, why in one patient it takes the direction of 
the lungs, in another of the mesenteric glands, in a third of the lymphatic 
ganglia. Hence I record the strumous diathesis, so ably depicted by Hufeland 
fifty-five years ago, and the tuberculous cachexia, no less ably portrayed by 
Sir James Clark thirty-five years afterwards, as but modifications of the same 
constitutional lesion. I have referred to these as being standard writers ; 
but it is proper to say that the majority of all who have written on these 
diseases, have with more or less distinctness, recognized this constitutional 
degradation which I shall generally designate by the term 



884 THE PRINCIPAL DISEASES OF THE 

Tubercular Diathesis. — Among the problems which etiology still 
presents for solution, there is not one of deeper interest than the cause or 
causes of this diathesis, seeing that the prevention of phthisis, so generally 
fatal, is only to be accomplished by obviating or correcting them. I propose, 
therefore, to direct the attention of the reader upon the known or probable 
sources of the constitutional lesion, rather than upon the therapeutics and 
pathological anatomy of fully formed consumption, thus keeping in mind 
the classical maxim, resist the beginnings, as pre-eminently applicable to this 
fatal malady. There are agents which can scarcely be regarded as capable 
of producing a tubercular diathesis, but may determine an earlier or more 
copious deposit of tuberculous matter in the organs, and others which may 
accelerate the development of inflammation, both of which, logically, should 
be referred to different heads \ but I find it convenient to speak of them in 
connection with the influences which are supposed to generate the predispo- 
sing diathesis, indicating as we pass along the manner in which they operate. 



SECTION I. 

RELATIONS BETWEEN CLIMATE AND THE CONSUMPTIVE OR TUBERCULAR 

DIATHESIS. 

I. Statistics of Consumption. — The long-established connection, both 
in the professional and popular mind, between consumption and the cold, 
variable, and humid climates, suggests the propriety of proceeding from 
North to South, in the inquiry on which we are now entering. To this 
inquiry the statistics of our Interior Valley can contribute very little, 
and I have, therefore, looked to the Atlantic States, Nova Scotia, and the 
West Indies. In arranging them into a tabular form, I have kept the 
military and civil returns in distinct series, arranging both, as near as 
possible, according to latitude. The stations and regions generally, 
it will be seen, are not only, in general, contiguous to the sea, but near its 
level; none a thousand feet above it. 



INTERIOR VALLEY OF NORTH AMERICA. 



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MILITARY RETURNS. 

rving at home: Europe, 
Nova Scotia and New Brunswick, A 
e Canadas : inland and lacustrine, 
around and among the Northern La' 
on the sea-coast, from Maine to Ne 1 
inland ; Upper Mississippi, from For 
Gibraltar, Malta, and the Ionian Isl 
, sea-coast, from Pennsylvania to N. 
inland ; Lower Mississippi to Baton 
ermuda Islands, Atlantic Ocean, 
sea-side, from Charleston and New 
eward and Windward Islands, Baham 
ops in the same places, 


CIVIL RETURNS. 

ncluding Boston, 
exclusive of Boston, 

Blacks, .... 

.iding London, 

$ excluding cholera, ) 
' ( including cholera, \ 


Z 
<J 

CO 

o 

a 




-2 t^ -2 ^ c 00 




1 1 1 „ • I g jf • • £ • 9 • 




ritish troops se 
" " in 
" " th 

merican troops 

ritish troops at 
merican troops, 

ritish troops, B 
merican troops, 
ritish troops, Le 
ritish Black tro 
veragc, 


State of Massach 
State of Massach 
Boston, Massach i 
City of New Yorl< 
Baltimore, 
Charleston — Whii 
— Whil 
—Blac 
New Orleans, 
Rochester, 
England and Wal 
Philadelphia, 

St. Louis, 1847 a: 

London, 




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886 THE PRINCIPAL DISEASES OF THE 

Before we proceed to inquire into the conclusions which may be drawn 
from this table, we must consider the objections which lie, or seem to lie 
against some of its elements, that we may the better estimate their value 
and bearing. 

It may be objected to the first division, that it relates only to persons of 
a certain age, chiefly between the twentieth and fiftieth years. This is true, 
but I find by the Massachusetts bills of mortality for 1845-1848, that pre- 
cisely one-half of the mortality from consumption is in that period, and 
hence the returns express it for the whole period of life. It may be further 
objected, that this division presents the deaths of men only, while consump- 
tion prevails still more among women. This objection is well founded, for 
the Massachusetts' returns show that the difference between the sexes from 
the twentieth to the fiftieth year, is as four males to seven females ; and 
hence the military reports do not adequately represent the general ratio of 
mortality. It may be still further objected, that young men, apparently 
inclined to consumption, are not often enlisted, and therefore the mortality 
from that disease would be greater in an equal number of men taken indis- 
criminately, which is doubtless true. It may also be objected that the 
returns relate chiefly to natives of the higher latitudes, while their service 
was largely in the South, and not to natives of the South serving in the 
North. It may be still further objected that soldiers lead irregular and ex- 
posed lives, beyond the mass of the people in civil life. It is not true, how- 
ever, that whatever may be their propensity to intemperance, it is oftener 
indulged than it is by an equal number of the same class of persons out of 
the army, nor, in general, are they more exposed than the poorer classes of 
every country. I believe, therefore, that the figures in the military division 
of the table, especially the British portion, give us an approximative ratio 
of the general mortality from consumption on our continent and islands. 

If the military division of the table present us with the mortality from 
consumption among a particular class of men, soldiers, the civil division, with 
one exception, presents us with the mortality in a particular class of locali- 
ties — cities. By comparing these with the country, as Boston with Massa- 
chusetts, we discover that they give too high a ratio for the latter. We 
must also bear in mind, that these cities are all- maritime, and, with the ex- 
ception of Charleston, are places of large immigration from Europe. Finally, 
it is necessary to a just estimate of the character of our returns, to recol- 
lect that consumptives, whether predisposed or actually ill, are constantly 
travelling or migrating from the northern to, or through, the more southern 
cities, the reverse of which scarcely ever happens. 

II. Etiological Deductions. — I. Let us look at this table in reference 
to the connection between climate and consumption ; having regard, in the 
first place to mean temperature. The annual mortality from that disease in 
the British army is 40 out of 10,000 in Canada, and 46 in Nova Scotia, but 
rises to 59 in the Bermuda Islands, and 63 in the West Indies. In addition 



INTERIOR VALLEY OF NORTH AMERICA. 



887 



to this, I may mention what does not appear in the table, that in the dra- 
goons and dragoon guards of the British army, serving at home, the 
number of cases of consumption treated, was, through a series of years, 
between 6 and 7 per 10,000 annually ; while in Jamaica it was 13, or 
twice as many, the men being, like those in the table, of the same nation. 

Our own sea-side posts, north of New York, give 43 ; those south of that 
city, as far as the southern border of North Carolina, give 63 per 10,000. 
The same is true of the posts in the Valley of the Mississippi ; those above 
St. Louis giving 35, those below, 62 in 10,000. The posts around the 
northern Lakes, between the 42d and 47th parallels, contrast still more 
strikingly with those around the Gulf of Mexico, between the 32d and 24th 
parallels, for the former give only 19, while the latter give 68 out of every 
10,000. Massachusetts, Boston, New York, and Baltimore, give respec- 
tively 26, 44, 43, and 42, while Charleston gives 37, and New Orleans 49. 

The black troops who are natives of the West Indies, give the ratio of 
88 in 10,000, while the black population of Charleston give only 39. The 
mortality of the former, from this disease, is in fact higher than that of 
the white troops serving in England, which is 77 in 10,000. When we 
compare the latter with troops which serve in the Mediterranean, a different 
result is presented, but it is more apparent than real. Thus the average 
for Gibraltar, Malta, and the Ionian Islands is 32 per 10,000, or less than 
half as much as in England. This, however, is but 8 in 10,000 less than 
in Canada, while it rises 6 in 10,000 over Massachusetts. According to 
Major Tulloch, moreover, the returns do not indicate the full prevalence of 
consumption among the troops serving in the Mediterranean ; as it is the 
invariable practice to send to England all who become permanently infirm; 
and therefore many consumptives die on the voyage, or after reaching home, 
and of course do not appear in the Mediterranean returns. On this point, 
that able statistician is perfectly explicit, and expresses the opinion in re- 
ference to Gibraltar, that if the number sent away to die could be included 
in the returns of deaths from that post, it would be seen that it is as much 
infested with consumption as England herself. This, indeed, he demon- 
strates by the following table.* 





Aggregate 








strength of 




Ratio per 1000 




seven years, 


Total attacked 


of mean 




from 1830 to 


by consump- 


strength at- 




# 1S36 inclu- 


tion in these 


tacked an- 




sive. 


seven years. 


nually. 


United Kingdom, ..... 


43,163 


286 


6-6 


Gibraltar, ...... 


22,868 


187 


8-2 


Malta, 


15,031 


101 


67 


Ionian Islands, ...... 


24,401 


129 


5-3 


Average of the Mediterranean States, 






6-7 



Thus it is shown, that at all the Mediterranean stations, the average ratio 

* P. 63, a. 



17 attacks, 


•9 deaths 


29 " 


•6 


30 


1-8 


23 


•9 



888 THE PRINCIPAL DISEASES OF THE 

of attacks of consumption is precisely the same as in England ; at Gibraltar, 
even greater, in the proportion of 8-2 to 6-6; and with this fact I may 
connect the remark, that among the civil population, around that post, con- 
sumption bears the same relation to all other diseases as among the 
military. 

Nor is the climate of the Mediterranean less productive of those inflam- 
matory affections of the lungs which consumptives so much dread ; for in 
another table, where they are substituted for consumption, the places and 
numbers remaining the same, we find the annual attacks and deaths in 1000 
to be as follows : — 

England, 

Gibraltar, 

Malta, .... 

Ionian Islands, 

The average of the three latter 1-1 is -2 greater than the ratio in Eng- 
land, while the ratio of the island of Malta is double.* 

The military returns, then, not in fact contradicted by the civil, show a 
greater mortality from consumption in the South than the North. But they 
do not prove that in the white man the diathesis is generated there, for' 
these soldiers were from the latter, and might have taken the diathesis with 
them. But if that were the case it is demonstrated that the heat and mois- 
ture of the tropics and the fevers which break down so many constitutions, 
are more powerful exciting and co-operative causes than any which prevail 
further north. We may suspect, however, that agencies capable of pro- 
ducing such effects, may also be instrumental in generating the diathesis ; 
and this is rendered almost certain by a reference to the black troops of the 
West Indies, whose ancestors never resided in a high latitude. According 
to the table, 88 of 10,000 die annually of consumption, which is the greatest 
known mortality from that disease, and when contrasted with the ratio in 
Charleston, 39, shows indubitably a more pernicious climatic influence be- 
tween the tropics than in the latitude of 33° north. I am aware that the 
blacks of Charleston may be living under circumstances more favorable to 
health than the black troops of the Islands, but cannot conceive of so great 
a difference in the mortality from that source. 

Do our statistics show a difference in the prevalence of consumption, be- 
tween the seaboard and the Interior Valley in the same latitudes ? It is 

* The British reports give a mortuary tahle of the civil population of this island from the year 1S22 
to 1834 inclusive; the average population being ]00. 270, from which it appears that the annual mor- 
tality is 1 in 39, or 257 per 30.000. This is far greater than the mortality of Massachusetts; and the 
same with that of the white population of Charleston. I regret that these returns present the terms 
phthisis pulraonalis, consumption, and marasmus. Major Tulloch, hesitatingly, has included them 
under the two former heads, by which, according to our understanding of the terms, but one disease is 
indicated. He supposes that tabes niest-nterica was included in consumption and also many of the un- 
defined infirmities of old age. Most of the deaths were probably from tubercular disease, and if so, 
they show a mortality from that malady of 33 in 10,000, or one out of every 305; which is about an 
eighth part of the mortality of the island; from which, again, we are instructed that those who labor 
under a tubercular diathesis, ought not to seek relief in the Mediterranean. 



INTERIOR VALLEY OF NORTH AMERICA. 889 

not easy to answer this question conclusively, from the want of information 
concerning the prevalence of that disease in the cities of the latter region, but 
one of which, St. Louis, appears in the table. Comparing it with Baltimore, 
the two lying nearly in the same isothermal curve, and differing in elevation 
but four hundred feet, we find that St. Louis has the advantage of 13 in 
10,000. When we look at the military reports, we see that Nova Scotia 
rises 4 in 10,000 above Canada ; that our own seaside posts north of New 
York, rise 8 in 10,000 over those of the Upper Mississippi; but the mari- 
time posts south of New York, are only 1 in 10,000 higher than the posts 
south of St. Louis. Thus, on the whole, the numbers in the table indicate 
a greater prevalence on the sea-coast than in the interior. 

Now, what are the climatic differences between them ? The. answer is, 
that the interior posts are most subject to violent changes of temperature — 
the maritime to humidity j yet these diversities do not appear to exert any 
influence on the prevalence of the disease. 

Our lake posts present some data for estimating the comparative influence 
of fresh and salt water localities. They are seven in number, and the 
figures which represent the mortality from consumption in 10,000, are only 
19, representing less than half the prevalence on the sea-coast from New 
York to Nova Scotia. I confess that I doubt the correctness of this low 
ratio; but until it is corrected by additional observations we may say that 
pur lake-shores enjoy a far greater immunity from consumption than any 
other portion of the United States. 

Admitting this to be a fact, I am unable to offer an explanation. It can- 
not be referred to moisture, for the seaside posts in the same latitude have 
an atmosphere equally abounding in (salt water) humidity ; nor is it refe- 
rable to difference of mean temperature, for that is nearly the same both to 
the east and west of the Lakes : there is one difference, however, the sum- 
mers are cool and fresh ; but I cannot venture to ascribe the difference in 
consumption to that cause, and shall leave the matter subjuch'ce, with the 
single remark, that as the garrisons around the Gulf of Mexico suffer from 
consumption more than three times as much as those around the Lakes, the 
anomaly presented by the Latter furnishes no evidence in support of the 
current opinion concerning the origin of a tubercular diathesis from cold 
and moisture. 

It has long been a popular opinion that consumption is less prevalent in 
regions where the periodical fevers prevail than in others lyisg in the same 
latitude ; and in the course of my travels through the Interior Valley, I 
have been repeatedly told that the disease was becoming more frequent as 
those fevers, from increasing density of population, and consequent cultiva- 
tion of the country, became rarer. But all the statistics through which we 
have travelled indicate this greater prevalence as comparative and not abso- 
lute, a diminution of autumnal fever being mistaken for an increase of con- 
sumption. They, in fact, demonstrate that the cause of periodical autumnal 



890 THE PRINCIPAL DISEASES OP THE 

fever is not preventive of consumption; that the two diseases do not antago- 
nize each other. I have indeed seen them combined in the same subject. 
On our seaboard, periodical fevers prevail much more south than north of 
New York ; and so does consumption j they prevail more on the Lower 
than on the Upper Mississippi, and the same is true of consumption ; in 
Nova Scotia, they are almost unknown; in the West Indies, more prevalent 
than any other diseases, and yet consumption prevails less in the former 
than the latter; finally, those fevers occur but seldom in Boston, while 
they are never absent from New Orleans ; yet the ratio of deaths from 
consumption is 71 per cent, greater in the latter than the former. These 
facts are not merely conclusive against the prophylactic power of what is 
called a malarial atmosphere, but seem to indicate that its effects are inju- 
rious to those who are predisposed to consumption, and may be one cause 
of the greater mortality from that disease in the South than the North. 

The errors that malarial districts and hot climates are preventive of con- 
sumption have had the same origin. In both cases they came from com- 
paring the mortality from that disease with the general mortality, instead 
of with the population ; and as that mortality is great in hot countries 
where periodical fever is the reigning disease, the mortality from consump- 
tion seemed very small. Thus, when it is said that in Nova Scotia one- 
third of all the deaths are from consumption, while in the West Indies 
they make only a fourteenth, the mind is impressed with the idea of a far 
greater mortality from that disease in the former than the latter region, till 
by further examination, it is found that the general mortality at the southern 
stations is six times as great as at the northern, and that the deaths from 
consumption are also greater in the proportion of 62 to 46 in every 10,000 
soldiers. To illustrate this still further, we may refer to our own posts 
north and south of New York, on the Atlantic coast. At the former, 
consumption causes nearly a third of all the mortality; at the latter, about 
a sixth; yet, but one out of every 230 die of that disease at the northern, 
while one out of every 159 perish from it at the southern posts, where, 
from the overshadowing mortality of other causes, it seems to prevail the 
least. Finally, when we look at Boston, we find that the deaths from con- 
sumption make nearly a seventh of the whole, while in New Orleans they 
make a little less than a fourteenth, yet, in the former city, there is one 
death from consumption out of every 227 — in the latter out of every 205 
persons. 

III. Speculations on the Modus Operandi op Climate. — Thus far 
we have been occupied on facts, and a few obvious deductions from them. 
They may include errors of observation, which future inquiry will correct, 
but I have sought to preserve them unadulterated from hypothesis. As 
speculation, however, when kept within legitimate bounds, is one of the 
means by which ulterior truths may be reached and the sciences put for- 
ward, I propose to devote a few pages to the modus operandi of climate in 



INTERIOR VALLEY OF NORTH AMERICA. 891 

the (supposed) production of a tubercular diathesis, and its most ordinary 
issue, pulmonary consumption. 

1. The Arctic Regions. As one of the poles of cold for this hemisphere 
is found at the northern extremity of our Interior Yalley, a climate, which 
in Europe would be called Arctic, exists ten or twelve degrees south of the 
circle bearing that name ; and, therefore, the coasts and islands to which I 
now refer, are those above lat. 60°. I shall take five degrees as an ave- 
rage of their different mean annual temperatures, which is about that of the 
Arctic Circle itself. The permanent inhabitants of these regions are Esqui- 
maux, who live without exception on the sea-coasts, and for most of the year 
inhabit snow houses. From the year 1818 to 1833, many voyages and 
travels of discovery were made by British navigators into those icy regions ; 
and in 184-8 they were renewed. Thus we have acquired some data for 
estimating the prevalence of consumption in the frigid climates, but none 
which could be introduced into the table.* 

In examining the abridged and mutilated histories of these voyages and 
travels, which have been republished in this country, I find a reference to 
but two or three cases of consumption among the Esquimaux, and it does 
not even appear whether they were tubercular or only bronchitic. Captain 
Franklin and Dr. Richardson, who for two summers had extensive intercourse 
with the Esquimaux, inhabiting the coasts and islands east and west of the 
mouth of M'Kenzie River, give no evidence of the prevalence of consump- 
tion among them. Captain John Ross, who kept up intercourse with a tribe 
of those savages for the three years that he remained with his ice-bound 
ships, in the latitude of 70°, where he found the mean temperature less 
than 4°, does not speak of that malady ; and Dr. Edwards, the surgeon of 
Captain Parry's ship, which spent two years under the Arctic Circle, in 
about the same temperature, informs us, that two hundred and fifty-five 
Esquimaux passed a year near the ships, during which eighteen died, yet 
not one perished from consumption, and their diseases were more abdominal 
than thoracic. 

Among the voyagers and travellers themselves, consumption seems to 
have been equally rare. In referring to those of the first period, 1818-33, 
I find that the sojourn in those regions was equal to that of 1000 men for 
a year, yet but two deaths from consumption is mentioned, and in one of 
the patients it had commenced, according to Captain Ross, before he left 
England ; yet, by the table, at least seven would have died in England or 
the West Indies in the same time of that disease. It appears, then, that 
the climate of our Arctic regions is but little productive of consumption ; 
and it seems probable, that the same is true of the Asiatic regions lying 
around the other pole of cold ; for, on consulting the travels of Wrangell 
and Erman, I can find no evidence of its existence there. 

Now what are the characteristics of the climate which is thus nearly 

* See Vol. I. p. 459, and other parts of the article Climate. 



892 THE PRINCIPAL DISEASES OF THE 

exempt ? Its mean summer heat is but 35°, or 2° above the winter heat of 
Cincinnati, while its winter heat is — 26°, a lower average temperature for 
three months, than Cincinnati has ever experienced for a single day. The 
effect of this great cold is to precipitate nearly all the water from the atmo- 
sphere. In spring and autumn, however, the air becomes damp ; for during 
the former, when the winds become southerly, their vapor is condensed by 
the cold into fogs, and in autumn, when the air becomes chilled, the vapor 
of the ocean water undergoes the same condensation. In summer, however, 
as in winter, there is not much obvious humidity ; for the heat of the 
atmosphere is sufficient to keep the limited evaporation from the sea in 
complete solution. 

The direct and sensible effect of this cold air on the lungs seems to be in 
no respect injurious or uncomfortable. At Melville Island, when the tem- 
perature was — 56°, or 17° below the freezing point of mercury, the seamen 
could walk abroad without inconvenience, and seldom had even a mild 
catarrh. It appears, indeed, that the lungs have no sensibility to caloric, 
and do not feel the impress of an atmosphere 150°, or even 160° colder 
than themselves. We cannot doubt, however, that the respiration of such 
an air must produce on the organism effects of a different kind from those 
produced by the air of temperate and hot regions. Its absolute quantity of 
vapor at saturation, taking the temperature of 5°, is only -0572, or five hun-. 
dred and seventy-two ten thousandths of a grain in one cubic foot; while at 
Cincinnati, Louisville, and St. Louis, with a mean temperature of 55°, it is 
•5419, or ten times as much ; and within the tropics, at the mean heat of 
80°, it rises to 1-1727, or twenty times the amount.* The effect of this 
low temperature on the density of the air equally deserves notice. It is, for 
the year round, greater than that of the coldest day of the past winter. Ac- 
cording to Captain Parry, on Melville Island, when the mercury falls to — 50°, 
the density was so great that in the elemental silence of the Polar night, 
common conversation could be distinctly heard and understood beyond a 
mile. 

But we may subject the difference between the Arctic and tropical atmo- 
spheres in this respect to calculation, and construct a table of decreasing 
density from increasing temperature, allowing for each degree of added 
caloric an expansion of 1490th of the bulk. From this table I find that in 
rising from 5°, or the Arctic mean temperature, to 80°, or that of the tropics, 
a diminution in the weight of the inspired air of one-sixth. Thus taking 
twenty cubic inches as the amount of each inspiration, the man of the tropics 
would inspire of his rarefied atmosphere only as much as would make 16-66, 
or five-sixths of that taken into the lungs of the man of the circumpolar 
regions. And when we take the Arctic winter — 26°, and the tropical sum- 
82° = 108, the difference rises to nearly one-fourth. 

Now what must necessarily happen from the respiration of such an atmo- 

* See Table, vol. i. p. C02. 



INTERIOR VALLEY OF NORTH AMERICA. 893 

sphere as that of the Arctic regions ? The first fact which presents itself is 
the larger quantity (in weight not volume) of air taken into the lungs at 
each inspiration, than in the temperate and torrid zones, hence the greater 
supply of oxygen to the blood, and the freer escape of carbon from it. The 
next is the renewed or the secondary expansion of the air vesicles, from the 
rarefaction of the cold and dense air by the heat of the body. This rare- 
faction commences with the inspiration, and continues to increase without 
any escape of air through the bronchial tubes and trachea, until the begin- 
ning of the expiration ; and in proportion to the reduction of temperature 
will be the secondary dilatation of the air-cells; which must be, as we have 
just seen, a sixth part, or 166 per cent, greater than in the torrid zone. 
Thus while more oxygen is supplied, a greater surface is afforded for its 
endosmosis to, and the exosmosis of carbon from the blood • the capillary 
vessels at the same time becoming proportionately multiplied or enlarged in 
their diameters, and thereby securing to the blood a readier passage through 
the lungs. 

Another effect is connected with the vapor of the atmosphere. Air at the 
temperature of 5° is capable of holding only (-0572) five hundred and 
seventy-two ten thousandths of a grain of water dissolved in the cubic foot, 
but when raised to the temperature of the expired air, about 80°, it can con- 
tain, without supersaturation, 1-1727 in the cubic foot. Now this capacity 
for receiving vapor is but another expression for the power of acquiring or 
taking it, water being in contact, as of course it is in the lungs. If then 
air, even saturated with vapor, which it seldom is, at the temperature of 
5°, be inhaled, and its temperature be raised to 80° or upwards, it follows 
that if the lungs afforded no water, it would be expired excessively dry, 
but we all know that such fact is not the case. It therefore extracts, as it 
were, the moisture of the lungs, in other words, greatly promotes pulmonary 
exhalation. But if an air, of the temperature of 80°, saturated with vapor, 
were breathed, pulmonary exhalation would be nearly suspended ; or if it 
did not contain more vapor than would saturate air at 50°, still it could 
only receive the vapor which 30° of temperature, that between 50° and 80°, 
would enable it to receive ; while in the other case it would take as much as 
could be received, by the rise of temperature through 75°, that is, from 5° 
to 80°. It appears then that cold air received into and heated in the lungs, 
is a great promoting cause of pulmonary exhalation in the Arctic regions ; 
operating on that exhalation as successfully as a hot air operates on the 
exhalation from the skin in the tropical regions. Now there is dissolved in 
pulmonary vapor a portion of animal matter, constituting the lungs an 
organ of excretion for the decaying molecules of the tissues, as well as for 
the carbon of the blood ; and we may safely believe, that this is one of the 
modes in which the respiration of a cold air contributes to health and vigor 
of constitution. 

But to what extent does an Arctic temperature affect the functions of the 



894 THE PRINCIPAL DISEASES OP THE 

skin ? It undoubtedly lessens its secretion. We must, however, bear in 
mind that the skin is the seat of that sensibility, by which we take cogni- 
zance of the presence of caloric, and unlike what happens in regard to the 
undulations which raise in us the sensations of sight and sound, the absence 
of which imparts no feeling ; the absence of caloric gives us pain, whereby 
we are prompted to defend ourselves against cold. This in the Arctic 
regions is effected by abundance of fur, and wool, and hair, very imperfect 
conductors of caloric, without which life could not be preserved; and 
although the temperature of the space between this covering and the skin 
may not have as high a temperature as that in the warmer regions; the sur- 
face has the benefit of a more equable degree of heat ; for the sudden vicis- 
situdes of the temperate and many parts of the torrid zone, are almost un- 
known in the Arctic, and therefore the skin is not exposed to their action 
as it is in the latter. That surface, moreover, is held by the physiolo- 
gists to throw off two secretions — a vaporous, by simple exosmosis, and a 
fluid by secretion. Now it may be presumed that it is in the latter, that 
the animal matters chiefly exist, and that, it is quite conceivable, may go 
on although the former may be impaired. That it is not suppressed, how- 
ever, we have abundant evidence in the well-observed fact, that when the 
cold is below the freezing point of mercury, an individual may walk abroad 
without feeling it in the covered part of his body, if the air be calm, but 
under the slightest breeze it becomes insupportable from the increased 
evaporation from his dress, indicating that it contained moisture from his 
body. 

We must not, however, overlook the invigorating influence of cold on the 
vital properties of the solids ; but as this can be best presented in connec- 
tion with heat, I shall refer it to the next head. 

2. Let us now for the purpose of contrast, pass from the Arctic to the 

Torrid Zone. — We have taken the average mean temperature of the 
former at 5°, and the latter is known to be about 80°. The difference is 75°, 
and while one is 93° below the heat of the body, the other is but 18°. These 
numbers refer to the year, but the heat in the South often rises to 104° or 106°, 
in the North falls to —50° or —54°, giving a range of 160°, only 20° less than 
the range between the freezing and boiling points of water. The capability of 
inhaling air at temperatures so diverse without the feeling of heat or cold in 
the lungs, seems to prove, as I have already said, that they are not endowed 
with sensibility to caloric, in other words are indifferent to mere tempera- 
ture, and hence that it is not by the direct action of hot or cold air on those 
organs, that injury is done to them. 

But as the density of the atmosphere between the tropics is a sixth part 
less than in the circumpolar regions, it follows that the lungs, as we have 
seen, take in a less weight of air at each inspiration, and that having already 
nearly the same temperature of the body, it does not expand in the lungs, 
and give that secondary dilatation of the air-cells, which occurs in the 



INTERIOR VALLEY OF NORTH AMERICA. 895 

North. Still further, it has been ascertained by experiment that less carbonic 
acid is given out in warm than cold air ; but if less oxygen be supplied to 
the lungs, from the greater rarity of the air, is there on that account less 
elimination of carbonic acid ? According to experiments on cofc?-blooded 
animals, which can live for a time in hydrogen gas, oxygen is not necessary 
to the exhalation of carbonic acid, yet from the fixed relation between the 
absorption of one and the exhalation of the other, from the high probability 
that the imbibed oxygen is that which unites with carbon to form carbonic 
acid, and from the fact that the quantity of oxygen absorbed is precisely 
that, which, according to the law of diffusion of gases, is required by the 
amount of carbonic acid exhaled,* I am constrained to believe that whatever 
can diminish the absorption of one must lessen the exhalation of the other. 
I shall infer, then, that from two causes less carbon is eliminated from the 
lungs, in the tropical climates, and this may be one cause of the more 
copious secretion of bile, into the composition of which carbon so largely 
enters. 

But in all the sea and river-side localities of the torrid zone, the lungs are 
restrained in their watery exhalation, by the high dew point. If the in- 
spired air had a temperature not many degrees below that of the living- 
body, and at the same time be nearly saturated with vapor, it follows, that 
the watery exhalation from the lungs will be greatly reduced. It is not so 
in the Arctic regions, however, even when the air is saturated, for holding but 
a small absolute quantity of water, with a temperature far below that of the 
body, the heat which it acquires in the lungs enables it, as we have seen, to 
receive freely from the blood. It may be said, however, that the skin in 
hot climates takes on a vicarious function and prevents injury. But we 
may well doubt, whether one excreting organ or surface can fully and per- 
manently supply the place of another. The objects of the functions of ex- 
cretion are twofold : — 

First. To keep the water of the blood at or near a certain quantity, in 
comparison with the organic matters which it is to hold in solution or sus- 
pension. It is the medium of all molecular action in the living system, and 
therefore its excess or its deficiency must be unfavorable to molecular move- 
ment, and hence the necessity of thirst to keep up a good supply, and of 
organs of excretion to keep down excess. Now in reference to this end 
the organs of exosmosis are reciprocally vicarious j suppression of the per- 
spiration may bring on watery diarrhoea or diuresis ; excessive perspiration 
diminishes urinary secretion and checks diarrhoea; and retarded exhalation 
from the lungs in warm climates increases that from the skin and liver; in 
colder ones that from the kidneys. Thus, in reference to water, the organs 
of endosmosis are compensatory, and might permanently perform each other's 
functions. The water which flows off through all the outlets, cutaneous, 
pulmonary, renal, hepatic, and intestinal, is precisely the same fluid, and 

* Simon's Chem. of Man, p. 116. 



THE PRINCIPAL DISEASES OF THE 

passes out in the same mode, so that they may be regarded as different por- 
tions of one universal organ of aqueous excretion. 

Second. But although this provision against inundation of the organism, 
this guarantee of a certain and fixed degree of dilution, is an indispensable 
necessity, and the phenomena of life cease whenever the law is violated beyond 
certain limits, there is another and different end attained, by the function of 
aqueous excretion. Matters incapable of assimilation may find their way, 
by solution or suspension in the imbibed water, into the system, and they 
must be carried out, and the excrementitious portion of the tissues must 
also be eliminated. When one of the former is susceptible of being meta- 
morphosed by decomposition into an element of one of the excretions, this is 
done, but when not, it simply passes off with some excreted fluid, mingled 
but not combined with it. 

Now we have considerable evidence that these foreign and unassimilable 
matters do not, like excess of water, pass off indifferently through any 
organ, but that some take in preference one organ, others another, accord- 
ing to a law of relation between them and our systems, the very existence 
of which, like the other laws of nature, is made known to us by the pheno- 
mena to which it gives birth. It is not necessary that I should cite many 
of these phenomena. Sulphur seeks an outlet through the skin ; the 
odorous element of assafoetida and garlic through the lungs, whence also 
phosphorus injected into the veins escapes in the form of exhaled phos- 
phorous acid; turpentine, hydriodate of potash, and rhubarb choose the 
kidneys ; and tartar emetic, thrown into the veins, the mucous membrane of 
the bowels. Now it would be altogether oratuitous to affirm that these and 
all other unassimilable substances can pass off with equal facility through 
any of the organs of excretion, and we are rather called upon to believe, 
that in reference to them the reciprocally vicarious power of the organs of 
excretion is imperfect and limited. 

But the elimination of the worn out and therefore excrementitious mole- 
cules of the tissues, is a higher and more urgent need of the organism. 
They are not thrown off like the superfluous water indifferently through 
any outlet, nor do they pass out in the state in which they are detached 
from the tissues, but are combined into definite compounds, which by fur- 
ther union constitute the peculiar solid matters of the respective excretions, 
giving to each its characteristic qualities. Now, in reference to these, it 
may oe safely declared that, in the organs of excretion, there is not a full 
and permanent capability of performing each other's functions ; and in re- 
gard to those of the lungs and kidneys, especially, the vicariousness of the 
skin, liver, and bowels is so small, that life cannot be long supported by 
their utmost efforts. 

Let us apply this reasoning to the etiological inquiry in which we are 
engaged. Three excretions are thrown off from the lungs — carbonic acid, 
water, and animal matter dissolved in the water which exhales as vapor. 



INTERIOR VALLEY OF NORTH AMERICA. 897 

Now the other organs of excretion have so little vicarious power, in refe- 
rence to the carbonic acid, that life is immediately suspended when the 
lungs cease to throw it off, and we are therefore required to believe that 
any impairment of that function must produce injury to the system. As 
to the water, it might pass through other outlets, but then the effete organic 
matter, the peculiar animal element of the pulmonary secretion, would be 
retained ; and we have no more reason to suppose that it would be perfectly 
eliminated through the skin or kidneys, than that the peculiar matter of 
the urine would be adequately discharged through the lungs. Whatever 
hygrometric state of the air interferes then with the exhalation of vapor 
from the lungs, retards the escape of one of the peculiar matters of excre- 
tion, and begins the pathological state, which its continued retention can 
establish. As the amount of animal matter exhaled from the lungs is 
minute, no immediate perceptible injury may appear from the retention of 
a part, but this does not prove that it may not be a source of the tubercular 
diathesis, for that pathological state is always developed slowly; nor can 
we say that so small a failure of this excretion can produce no effect, for it 
is a violation of one of our physiological laws, and every violation leads to 
disease, which is but the state produced by some violation. 

By these lights we may perhaps see how a hot and humid climate may 
contribute to the production of a tubercular diathesis, more than one very 
cold, even cold and humid, and be the less staggered at the evidence of its 
prevalence within the tropics which our table presents. 

In this inquiry, however, we must not limit ourselves to the blood and 
its excretions, but look at the influence of heat upon the solids. 

Among the first applications of pneumatic chemistry to the blood were 
the speculations of Grirtanner, on the power of oxygen in maintaining irri- 
tability, and many facts drawn from comparative physiology indicate a con- 
nection between muscular firmness and activity and the quantity of oxygen 
imbibed; it may, therefore, prove an advantage, under this point of view, 
to live in a cold instead of a hot climate. The reactions moreover which 
follow on the applications of cold, are familiar examples of its invigorating 
influence. Still further, it has long been known that animals rendered 
torpid in all their functions, or even frozen, do not necessarily lose their 
contractility, but may be often resuscitated; and Edwards has proven, by 
direct experiment, that animals drowned in cold water can be revived after 
longer submersion than in warm. By these facts we are instructed that 
heat exhausts and cold preserves that fundamental vital property ; and 
hence we can understand how the temperature of the North may, by its in- 
fluence on the solids, maintain their strength and ward off a tubercular 
diathesis, while that of the South may enervate them, and favor its produc- 
tion, or growth. 

The experience of consumptives goes to illustrate this point. They dread 
cold and frosty weather, because it makes them cough; and hail warm 
vol. ii. 57 



THE PRINCIPAL DISEASES OF THE 

weather, because it does not irritate their lungs : the former they fear (and 
the apprehension is well-founded) may give them pneumonia, pleurisy, or 
bronchitis, but feel quite safe from such inflammation in mild and soft 
weather; hence they are ever avoiding cold and seeking heat. Now the 
very effects thus ascribed by an ample experience, to cold and hot weather, 
prove that the former heightens the vital properties and energies of the 
system, while the latter imparts no stimulation of that kind ; and it is the 
very want of this exciting and invigorating power in the tropical climates, 
that leads in part to the development or rapid and fatal advancement of the 
tubercular diathesis. 

3. We must now turn to the Temperate Zone. I have classed the 
northern eight or ten degrees of our temperate zone with the frigid, be- 
cause the isothermal curve of that zone, taking Europe as the standard, de- 
scends, on this continent, far into the temperate zone. We have indeed what 
in that continent would be called an Arctic climate, more than 10° south of 
the Arctic circle. Below this lies, for as many more, the Hudson Basin, 
within which there are but few people, and of their liability to tubercular 
diseases I know nothing. That portion of the zone in which reliable obser- 
vations have been made, lies south of the 50th degree of latitude, and em- 
braces the Lake or St. Lawrence, and the Southern or Gulf basins, extending 
through twenty-four degrees of latitude. The reader who has studied the 
climate of this great region,* is already aware that it combines the elements 
of the frigid and torrid zones ; falling short of both in everything but vari- 
ability, which may be called its great characteristic. This mutability is 
found in the temperature, weight, and density of the atmosphere, in its 
winds, cloudiness, humidity, and electricity, in the range of mean tempera- 
ture in different years ; in the great difference which they present in the 
quantity of rain, and in the displacement of the months or seasons; No- 
vember and December sometimes exchanging their ordinary weather ; Febru- 
ary assuming the functions of March ; April restraining vegetation with the 
power of the latter month; June often commencing a fortnight before the 
calendar time, and sometimes receding before the month of May, for an 
equal period. The climate of this portion of the temperate zone is not, in 
short, a neutral compound of the polar and equatorial elements, but an 
uncombined mixture, of no definite character. 

In Europe, to which for several reasons it becomes necessary to refer in 
this investigation, the changes are less sudden and violent, and the seasons 
less liable to displacement; the transition from the tropical to the Arctic 
region, is also at a lower ratio, and therefore the northern limits of popula- 
tion are found there at a much higher latitude. 

Whatever may be the absence, or uncertainty as to the existence of a tuber- 
cular diathesis in the frigid zone, there is none in reference to the temperate, 
within which, moreover, we find nearly all the civilized inhabitants of the 

* See Vol. I. B. I. p. 2. 



INTERIOR VALLEY OF NORTH AMERICA. 899 

globe, a tenth part of whom, if not more, die of that diathesis. Its con- 
nection with the climates of this zone, presents a most complicated and diffi- 
cult problem, for climate has both its direct and its indirect influences on 
the human constitution, and nothing is easier than to confound them. 
"Whether we take the same parallel of latitude, or the same isothermal curve, 
and follow it from the Atlantic coast to the Rocky Mountains, we find local 
variations of climate, arising from the contiguity of the sea, the elevation 
of mountains, the alluvial valleys of rivers, lakes of fresh water, marshes, 
forests, treeless plains, and barren soils ; yet consumption occurs throughout 
the whole ; and who can predict the time when the statistics of that malady 
will be so extensive and minute as to show which of these local modifica- 
tions most promotes the origin or growth of a tubercular diathesis ? But, 
under the same curve, we have sparse and compact populations, country and 
city, field and shop labors, toil and idleness, luxury and starvation, heated, 
and cold or damp lodgings, occupations which invigorate the body, and those 
which enervate it, atmospheres of great purity, and others abounding in 
mechanical, chemical, and organic impurities ; all of which may be regarded 
as negative or positive agencies, which cannot be overlooked in our estimate. 
If we all lived under the same isothermal curve, this diversity would pre- 
sent the task of a most difficult analysis ; but when we take another curve, 
only a few degrees north or south, we find not only new modifications of 
climate as we cross the continent, producing of course different effects from 
the last, but we see in the social modifications which the climatic differ- 
ences originate, another series of varieties in the modes of living, and the 
pleasures and labors of the people. Thus, in contemplating the diversities 
which prevail over the temperate zone, or even within an extensive region 
like our own Valley, we see that an exact determination of the relative 
agency of climate, and the different natural and social conditions to which 
it indirectly gives birth, must be an undertaking of the greatest magnitude 
and difficulty. 

It was on this account that I chose to compare first, the effects of the 
coldest and hottest climates, where but few other conditions exist to com- 
plicate the problem. To what was there said, I have but little here to add. 
During winter, we have the invigorating influences of the extreme North ; 
through summer, the enervating influences of the distant South. Above 
the isothermal curve of 54°, which cuts the Ohio River at an acute angle 
near its middle, we have a predominance of the former, — below it, of the 
latter. At one time, or in one season, the function of respiration (according 
to what has been said) is acted on beneficially, at another, injuriously ; 
neither continuing very long. Thus, in reference to this function, the salu- 
brious and insalubrious conditions somewhat counterpoise each other; but 
the same cannot be said of the function of the skin. In all variable climates, 
that surface is liable to be at times inadequately protected, and no fact is 
better established than the influence upon it of the vicissitudes of tempera- 



900 THE PRINCIPAL DISEASES OF THE 

ture and moisture. Of all the tissues of the body, it is the one which, as 
we have seen, has the highest susceptibility to caloric, and must, therefore, 
suffer in its functions from changes in the temperature around it more than 
tissues, like the pulmonary mucous, which have little susceptibility of that 
kind. We know, indeed, that heat excites its secretory action, and that 
cold even partially applied diminishes or suppresses it. Thus it is through 
this function, more than that of the lungs, that the variable climates of the 
Temperate Zone may contribute to the production of a tubercular diathesis. 
The increased secretion from the kidneys, when the functions of the skin 
is impaired, may be referred to as vicarious ; but although compensatory, 
as it relates to the exosmosis of water, it does not follow (from what has been 
said), that the solid matters, which it is the duty of the skin to excrete, 
are effectually carried out of the system by the urinary organs. But under 
the diversified occupations prevailing in the Temperate Zone, because it is 
temperate, there are many local or domestic atmospheres, which may, at the 
same time, impair the excretory functions of both the lungs and skin. We 
shall have occasion in the next section to point this out more fully, and thus 
show that in the Temperate Zone, where the character of what may be 
called the natural climate is not favorable to the production of a tubercular 
diathesis, there may be spots of an opposite kind, which being overlooked, 
may lead us into the error of ascribing a direct influence to the general 
climate in producing the diathesis, when its influence was indirect only as 
favoring the occupations which are carried on in a local, factitious atmosphere. 

The period of life in which all climatic influences — direct and indirect, 
positive or negative — are most likely to generate, or promote an hereditary 
tubercular diathesis, is that of adolescence, or growth. When the function 
of formative assimilation has ceased, and conservative assimilation only 
remains, climate may produce many various diseases, but has little power, 
I apprehend, in originating that diathesis. 

But aside from its effects in generating a tubercular diathesis, the climate 
of the Temperate Zone must be considered as to its immediate influence in 
the production of pulmonary consumption, — that is, as an exciting cause of 
tubercular pneumonitis. In this respect, it is no doubt more mischievous 
than the climate of the Torrid \ for every attack of pneumonia, catarrh, or 
bronchitis, in one who lias a consumptive diathesis, is likely to promote the 
deposit of tubercular matter in the lungs. It is this effect of the cold and 
variable climates, that has established in the public mind, a connection in 
the manner of cause and effect between such climates and pulmonary con- 
sumption j an error which has been sustained and disseminated in the pro- 
fession by certain theorists, who could see in that disease nothing but 
inflammation. Forgetting that tubercle may be deposited by secretion 
without inflammation, and may itself become the cause of inflammation, 
they assumed, that if inflammation from external causes could be averted, 
the patient would escape consumption ; and thus, while attending to a 



INTERIOR VALLEY OP NORTH AMERICA. 901 

secondary pathological element, the primary, and inevitably fatal one, has 
been too often overlooked, or placed in a subordinate position. 

IV. Hygienic Inferences. — From all that has been said it results, that 
the opinion long current in the profession, and never till lately called in 
question, that a tubercular diathesis owes its existence mainly to cold 
climates, is an error. On the other hand, as we have seen, it also prevails, 
caeter is paribus, less in cold than hot climates. But if this be not insisted 
on, more cannot at most be conceded, than as great a prevalence in one as 
the other, and, therefore, we can no longer call it a disease of the North, or 
connect it with degrees of latitude or isothermal curves. The hygienic rule 
which results from this conclusion, is equally obvious and important. He 
who has a tubercular predisposition, or labors under consumption in any 
stage, should not seek a warmer climate in winter, but a colder in summer; 
and, if he live far in the South, it might be well for him to remain in a 
colder throughout the winter. Happily, our Interior Valley abounds in 
eligible retreats for carrying out this requisition. Voyages to the Falls 
of St. Anthony, with a summer sojourn in Minnesota, now a settled region;* 
a residence on the Island of Mackinac, with excursions into Lake Superior;*)" 
voyages down the St. Lawrence to the cool and wild scenery of the Sague- 
nay;t and the Chatauque mountain-platform, at the sources of the Alle- 
ghany river,§ offer as attractive a variety as can be afforded by any country 
on earth ; and it should be recollected, in reference to the lake country, 
that our army returns, as given in the table, present it as more exempt from 
consumption than the Mediterranean, where one soldier out of every three 
hundred and eleven dies annually of that disease, while only one out of five 
hundred and twenty-six dies of it at our Lake military stations. In addition 
to these reports, the consumptives of Florida and Alabama, who may not be 
able to wander far from home, have a good resource in the beautiful Valley 
of the French Broad, Buncombe County, North Carolina, where, at the 
elevation of more than two thousand feet, they can enjoy the comparatively 
cool and invigorating influence of a climate, which I was assured by its 
physicians, is but little infested with consumption. 

What has been said implies a general recommendation to the consump- 
tive and the predisposed to remain at home in winter; but it equally implies 
that they should not confine themselves to hot rooms, but, contrariwise, 
should daily seek the open air. If they cannot bear it without cough and 
difficulty of breathing, it is because the tuberculation of their lungs has 
made great advances, although suppurative inflammation may not yet have 
been set up. That, however, is inevitable, and, when established, will 
advance to a fatal termination, the more rapidly the longer and more ener- 
vating may have been their confinement in hot apartments. 

Thus far I have spoken of general climate, and must now refer to local, 

* See Vol. I. p. 149. f Hud. p. 347. t Ibid. 432. § Ibid. 397. 



902 THE PRINCIPAL DISEASES OF THE 

•which is in most cases quite artificial. When a tubercular diathesis is 
forming under such circumstances, as, for example, in close villages, or 
dense and damp forests, or on alleys in the depths of cities, or in workshops 
and factories, where the air is confined, damp, and vitiated from the pre- 
sence of a great number of operatives, or the emplo} T ment itself, a change of 
local climate, only to be effected by change of place, is an indispensable 
condition to the arrest or retardation of the disease; and in making it, the 
patient should seek a fresh, pure, and invigorating atmosphere, cooler, 
instead of warmer, than the one from which he escapes. 



SECTION II. 

MISCELLANEOUS EXTERNAL CAUSES YVHICH ORIGINATE OR PROMOTE A 
TUBERCULAR DIATHESIS. 

I. The conclusion to which the inquiries of the preceding section brought 
us was, that the action of climate, in the production of tubercular diseases, 
has been overrated ; and all who adopt it will perceive the necessity of 
looking with renewed earnestness for other causes. In this section, I pro- 
pose to enumerate and consider those which are supposed to be operative, 
and we shall find that most of them are connected with our modes of living, 
and appertain largely to our civilization. When acting on the predisposed, 
they have justly been regarded as exciting causes of consumption; and in 
reference to the generation of a tubercular diathesis, they have been esti- 
mated as merely auxiliary to climate, which has been viewed as a causa 
sine qua non of that constitutional lesion. I am disposed to assign them a 
higher place on the etiological scale, and to insist that without the co-opera- 
tion of one or more of them, the direct climatic influences are not often 
productive of the constitutional lesion we are now studying. In short, I 
would place them on the same level with climate itself, and dropping the 
epithets principal and auxiliary, speak of the whole as co-operative causes. 
There is so much that is cheering in this view that one might desire to find 
it correct. Our climates cannot be changed, and, as we have seen, none are 
exempt from the disease ; but vicious modes of living, unhealthy occupa- 
tions, and insalubrious localities maybe reformed or abandoned; and in 
proportion as iliey are operative in the production of tubercular disease, it 
may be diminished by obviating them. This, it seems to me, is the point 
from which we can take the best view of our duty in reference to the pro- 
duction of those maladies. Before proceeding to recount these sinister 
agencies, it may be well to remark in reference to the whole that in propor- 
tion as an individual is inevitably exposed to the action of some, he should 
seek to extricate himself from the influence of others. His system might 
bear up against a few, and yet the addition of one more might begin a work 



INTERIOR VALLEY OP NORTH AMERICA. 903 

of physiological deterioration. He should not keep his eye on one only, 
that which happens to strike him as the most threatening, and rest his 
hopes of escape upon countervailing or diminishing its effects. He may 
greatly abate them, and yet fall a victim to other causes which had given 
him little alarm ; while, if they had been obviated, that which seemed most 
threatening might have proved harmless. 

II. Insufficient Exercise. — I have already discussed this subject, a 
branch of general hygiene.* Such is the nature of the living body, that 
deficiencies influence it as injuriously as excesses. A law is violated by our 
omitting what it enjoins, not less than by our doing what it forbids. In 
ethics and jurisprudence, the omission assumes the character of a positive 
offence ; and in hygiene, to neglect the performance of what a physiological 
law demands, is in all respects as bad as to do or suffer that which it re- 
quires us to avoid. An ignorance or inappreciation of this principle is the 
source of many diseases, and among them of that now under consideration. 
It is a law of our physiology, that during the growth of the body, it should 
exercise itself as the great means of acquiring a firm and healthy organi- 
zation. In the absence of all other causes of a tubercular diathesis, insuf- 
ficient exercise may not generate it; but with the co-operation of any it is 
one of the most fruitful. Its agency is, of course, most perceptible and 
pernicious in large cities, where it is one cause of the greater mortality than 
prevails in the country around. The physical development of many who 
are brought up there has the slenderness and softness of fibre which charac- 
terize the hereditary consumptive diathesis. Exercise, during growth, gives 
bulk and firmness not only to the muscles of locomotion, but to the heart 
and vascular system. This is a physiological law. According to another 
law, by quickening and deepening the respiration, it augments exhalation 
from the lungs, and thereby wards off that degradation of the albuminous 
elements of the blood, which favors the establishment or growth of a tuber- 
cular diathesis. At the same time, and to the same beneficial end, it in- 
creases excretion from the skin, the liver, and the bowels. Thus it is that 
agencies so unlike, as inactivity, insufficient diet, and variable and humid 
climate, concur in the 'production of the same constitutional lesion j and it 
follows, as a corollary from these premises, that habitual inaction is the 
most pernicious in those climates, wherever they may be found, which con- 
tribute most to the production of this diathesis. When we compare the 
annual mortality from consumption in Boston, one out of every 227 persons, 
with that of Massachusetts, one in every 382, we are logically required to 
ascribe a large portion of the difference, amounting to sixty per cent., to the 
more active or laborious exercise of the rural population in the open air; 
and so of our other cities compared with the country around them. Young 
men and women, children of rich parents, and brought up in idleness; 
young clergymen, lawyers, and teachers; boys and girls who are kept long 

* See vol. i. p. 696. 



904 THE PRINCIPAL DISEASES OF THE 

and steadily in schools, or work at handicraft employments, which require 
skill rather than strength, and are carried on within doors, such as clerks, 
shopkeepers, seamstresses, and apprentices, together with those who labor 
in large manufacturing establishments, where the power is not vital but 
physical, and the confinement protracted, are the classes of persons, whose 
nutrition of growth is most weakened and perverted by the negation of 
exercise. I have seldom seen a non-hereditary case of consumption in a 
young person of either sex which had not been preceded by this, as well as 
other violations of hygiene. In all the larger towns of the United States, 
this cause of a tubercular diathesis is on the increase; and as parents, guar- 
dians, and employers, either exert no authority, or give it a wrong direction, 
we cannot foresee the time when consumption, as far as it depends on this 
agency, will begin to abate. The experience of a long life compels me to 
look at this subject as one of deep and affecting interest, and the more so, 
because it seems quite impossible to make society view it in the same light, 
since the long-continued and impressive appeals of the medical profession 
have as yet produced no practical effect on the moral cachexia of those who 
hold in their hands the destinies of the young. 

III. Damp and Unventilated Habitations. — These, again, belong 
to the city much more than the country, and may be admitted as a cause of 
the greater prevalence of consumption. The log cabin of the latter may 
be rude and open in its construction, but is never without a blazing wood- 
fire in cool or wet weather, which keeps everything dry, and promotes a 
constant change of air, while the winds which play around purify the local 
atmosphere. But in our cities, families without number occupy each a 
single room, many of which are under one roof; they are often so close as 
to admit but little fresh air, and are generally warmed with stoves, which 
are less favorable to ventilation than open fires; many of these habitations, 
moreover, are so hemmed in by others, that refreshing winds reach them 
but sparingly, and the rays of the sun are almost excluded ; while others, 
in part or whole, beneath the level of the ground, are, of course, darker, 
damper and more certainly filled with a foul and stagnant atmosphere. The 
constant residence in such an air cannot fail to enfeeble the solids, retard 
excretion from the skin and lungs, and promote the absorption of impurities 
by the latter, whereby a tubercular degradation of the system is promoted. 
It is probably to lodgings of this kind (for, according to Major Tulloch, they 
are both limited and unventilated), that the high ratio of mortality, both 
among the white and black troops of the British army, in the West Indies, 
should be in part ascribed. In many of our own forts, the same condition 
of things exists, and is doubtless productive of the same results. Here, 
then, we have another cause which on the whole is increasing; for with the 
growth of our cities the proportion of these unhealthy habitations is aug- 
mented, and by generating disease, a fruitful source of poverty, they 
multiply the number of tenants. 



INTERIOR VALLEY OF NORTH AMERICA. 905 

IV. Bad Clothing. — It has been conjectured that the modern substitu- 
tion of cotton for woollen clothes is a cause of the increase of tubercular 
diseases. Cotton is certainly a better conductor of both heat and moisture 
than wool, and, therefore, less protective of the surface of the body. "When 
the air is both cold and damp, cotton apparel becomes moist much sooner 
than woollen, and the moisture facilitates the escape of caloric. Thus, in a 
chill and humid state of weather, or when temperature is very low, or the 
changes from heat to cold, or vice versa, are sudden and violent, the skin, 
defended with cotton fabrics, is more liable to impairment of function than if 
invested with woollens. Our children and youth, especially young females, 
are most obnoxious to whatever aid this mode of dress may contribute 
towards the production of a tubercular diathesis. Among the poor and 
those in moderate circumstances, cotton clothing is extensively used, from 
its being cheaper than woollen; but the rich, who have not this motive, 
dress in it to a far greater extent than is salutary. When our clothing is 
insufficient, we suffer injury by exposure; and to avoid that, impair our 
constitutions by long-continued confinement in close rooms through the 
winter. The substitution of cotton for woollen hosiery, and thin for thick 
leather shoes, is a part of the same system. Another item is the occasional 
exposure of the upper part of the chest, which from being generally covered 
inevitably suffers, when unprotected. Finally, the practice of confining 
that part of the body limits respiration, and interferes with active exercise, 
whereby the depuration of the blood, and the absorption of oxygen, which 
it is the function of the lungs to promote, is of necessity retarded. Thus, 
on the whole we can understand how errors of dress may contribute to the 
production of a tubercular diathesis, and as, cseteris paribus, it prevails most 
where they most abound, it seems logical to class them among its causes. 
Errors in bedding contribute to the same sinister result. The children of 
the rich generally sleep on soft beds with much covering in heated rooms. 
This renders their solids delicate, and their surfaces, both cutaneous and 
mucous, over-sensible to atmospheric changes, effects which favor the origin 
of a tubercular diathesis. But such lodgings are chiefly injurious to young 
persons who take but little exercise in the open air, and at the same time 
live luxuriously. To the hard laborer or him who subsists on a meagre diet, 
they are salutary, and this leads me to say that poor and badly clothed and 
fed children, to whom such lodgings would be a blessing, suffer great injury 
from sleeping without sufficient protection from the cold. The period of 
sleep is that in which the exhalation from the lungs naturally diminishes, 
and that from the skin should increase ; but if the young lodge cold, this 
function is impaired or suspended, and matters which should have passed out 
of the blood, are retained to vitiate its constitution. 

V. Bad or Poor Diet. — A habitually deficient diet, or one that is 
either of a bad quality, or simply innutritious, cannot long maintain a nor- 
mal condition of the blood or solids, and therefore may contribute to the 



906 THE PRINCIPAL DISEASES OF THE 

production of a tubercular diathesis. The experiments and observations 
which have been made on the effects of low diet in the inferior animals, are 
conclusive on this point. Yet in these experiments there were always 
other agencies present, as confinement, coldness, humidity, or darkness, all 
of which perhaps co-operated in producing a common effect. It is, espe- 
cially during the growth of the body, when more should be retained than is 
given out, that insufficient sustenance carries into the blood and solids a 
tubercular lesion. The serfs of Russia, inhabiting a climate not unlike that 
of the higher latitudes of our Valley, are subject to scrofula, which Crichton 
ascribes to their defective diet. The Indians of the northern part of this 
continent, are victims of the same disease, in part no doubt from the same 
cause ; but the climatic and other influences co-operate in both countries. 
In the West Indies, the negro population, as w'e have seen from the statistics 
of the British army, are greatly subject to consumption ; and I cannot doubt 
that a defective or not sufficiently diversified alimentation is a chief cause 
of this prevalence. The ration of the black troops, it is true, is the same 
as that of the white, which I give below ;* but the mischief is done, during 
the growth of the body, and consequently before entering the army. The 
difference in climate between the equatorial regions of Africa and the West 
Indies, is too small to account for the greater prevalence of this diathesis in 
the latter than the former. But the African nations are abundantly sup- 
plied with various kinds of nutritious fruit, and also eat rice, fish, meat, 
and milk; in short, are much better fed than their enslaved brethren in 
the West Indies. In the southern portions of our own Valley, the deficient 
diet of some plantations seems to promote a tubercular diathesis. Among 
orrr white population this can scarcely be regarded as a cause of much in- 
fluence, for no other people of the world are as well fed, especially with 
animal food. It has been received as a fact; that butchers, with their fami- 
lies and w operatives, are more exempt from tubercular maladies than other 
persons living under the same circumstances; and this has been ascribed to 
their eating more animal food. In Europe, the difference between them 
and others, is doubtless greater than in this country, where meat is so cheap 
that none are ever without it. The diet of the Esquimaux is entirely ani- 
mal, and, as we have seen, tubercular diseases seem to be unknown among 
them, or at least uncommon. Such facts appear to confirm the opinion, 
that a deficient diet, especially of animal substances, is a cause of tubercular 
disease. On the other hand, many writers enumerate indulgence in child- 
hood among the causes of that diathesis. It is certainly not impossible that 
excess of food may disorder the function of adolescent nutrition, especially 
when unaccompanied with much active daily exercise in the open air ; but 
I am not prepared to admit it among the causes of a tubercular diathesis ; 
and would assign, as its legitimate effects, the tubercular inflammations of 

* Weekly — bread 7 pounds; fresh meat 2 pounds; salt beef 2 pounds; salt pork 27 ounces; sugar 9 
ounces ; rice 10 ounces ; cocoa 5 ounces , and peas 2£ pints. Tulloch's Stat. Rep. West Ind. p. 5. 



INTERIOR VALLEY OP NORTH AMERICA. 907 

the brain, lungs, or mesenteric ganglia, which destroy so many, who, if they 
had lived beyond the age of puberty, would have died of tubercular pneu- 
monitis. 

VI. Alcoholic Drinks. — Nearly all writers on tubercular diseases enu- 
merate the abuse of ardent spirits among their causes. Some even regard 
that abuse as one of the most pernicious ; but my own observations do not 
lead to this conclusion. None of the many young women who annually die 
of consumption have been subjected to this influence, and a majority of the 
young men of this country who die of that disease, according to what I have 
seen, were either total abstinents or but temperate drinkers. It is easy to 
confound the enervating influence of drunkenness and debauchery in pro- 
moting the tuberculation of the organs when a hereditary diathesis exists, 
with the production of that diathesis. The former is, doubtless, a fact, the 
latter should at least be held subjudice. The effects of temperate drinking, 
and of early and moderate intemperance, are certainly not of a kind to 
generate a tubercular diathesis, if we may judge from the modus operandi 
of generally admitted causes ; and before the period of enervation and ex- 
haustion is reached, a peculiar diathesis, which may be called the alcoholic, 
is established, with subacute visceral inflammations, which are somewhat 
fitted to exclude every other cachexia. I am aWare that many of our army 
surgeons regard intemperance as greatly promotive of consumption, and I 
do not deny that in the predisposed it may be an exciting cause. We are 
now inquiring mainly into the agencies which generate a tubercular dia- 
thesis. 

VII. Occupations. — Some of these contribute to the generation or 
growth of a tubercular diathesis simply because they preclude exercise, or 
confine the patient in damp, crowded, and un ventilated places. Others are 
supposed to produce the same effect by requiring the trunk of the body to 
be thrown into constrained or unnatural postures, others by subjecting the 
bronchial membrane to the impress of mechanical atmospheric impurities. 
Of the first I have already spoken, but may here add that crowded work- 
shops must necessarily have an atmosphere unfavorable to the elimination 
through the lungs of both carbonic acid and effete animal matter ; for, ac- 
cording to the laws of exosmosis, if the air were saturated with those exha- 
lations, none could pass off by respiration ; and hence it follows that in 
proportion as it becomes impregnated with them, further elimination is im- 
peded. In further support of this proposition, I may refer to the researches 
of Dr. Lombard, in Geneva, which show, that consumption is twice as fre- 
quent in persons whose occupations are sedentary and carried on in shops 
and manufactories, as in " those who labor or take active exercise in the 
open air."* The second class, when they are of a kind that interferes with a 
free and defecating respiration, may aid in producing the constitutional 
lesion, but it is, I think, chiefly by embarrassing the lungs, and thus favor- 

* Tulloch. 



908 THE PRINCIPAL DISEASES OF THE 

ing the deposition of tubercular matter, that they act injuriously. As to the 
inhalation of air loaded with mineral dust, or the fuzz of hemp or cotton, I 
cannot grant that it contributes to the origination of a tubercular diathesis, 
though the conditions under which such an atmosphere is breathed may 
have that effect. But although these impurities may not originate or even 
promote a tubercular diathesis, they are exceedingly injurious to those in 
whom it exists, by irritating the lungs, and thus inviting an earlier deposit 
of tubercular matter. Hence they rank among the exciting causes of tuber- 
cular pneumonitis, but are not producing causes of the diathesis, without 
which that disease cannot exist. In the predisposed they may bring on 
consumption — in the unpredisposed they cause subacute bronchitis. 

The causes included under this head are of course most prevalent in cities ; 
the general and natural climate of which is of course the same as that of 
the country around them. In England, consumption being 100 in the 
country, is 125 or 25 per cent, more in the cities.* In London, where the 
population is so dense as to allow only 35 square yards to each individual; 
the general mortality is 342 per 10,000 — that from consumption 48*5 per 
10,000 ; where each person enjoys 119 square yards, the numbers are 278 
and 40-5 per 10,000 ; where each has 180 square yards, the numbers are 
228 and 37-5 per 10,000; in Massachusetts, the numbers for the country 
are general mortality 122, consumption 26 ; for Boston 336, and 44 per 
10,000. These, statistics indicate a high degree of influence in the causes 
which have been enumerated, and show us that climate is less injurious than 
we have heretofore been taught to believe. 

VIII. Hygienic Rules. — The prophylaxis suggested by what we have 
travelled over is so obvious, that I refer to it for the sole purpose of urging 
its observance. Assuming that the agencies which have been enumerated in 
connection with climate, may generate a tubercular diathesis, it follows that 
the avoidance of them will prevent its production. Not the absolute avoid- 
ance of all, for that may not be necessary, and is seldom practicable ; but 
the withdrawal from, or removal of as many as may, in every case, be under 
our control. To this end every physician, all boards of health, industry, and 
education, and all municipal corporations, should turn their attention with 
enlightened and persevering energy, for nothing can be confided to the future 
victims of the disease ; and the poverty-stricken are in general ignorant and 
helpless. They see not the distant approaches of the fatal malady, and 
when it comes, regard it as a part of their destiny. In our efforts at pre- 
vention, the great fundamental truth should be ever present in the mind, 
that the causes of a tubercular diathesis exert their sinister influence in 
childhood and youth. The growth determines the future physical character 
of the man, as the materials and. mode of building determine the stability 
of the edifice — which on its completion may promise well in appearance, and 
yet soon begin to crumble away. 

* Second Report of the Registrar General of England. 



INTERIOR VALLEY OF NORTH AMERICA. 909 

Of the various causes included in this section, the one which in our Inte- 
rior Valley is most pernicious, is deficient esercise in the open air. I need 
not here repeat what has been already said,* but may urge its special appli- 
cability to the disease we are now studying. 

But all causes of a tubercular diathesis wiH of course aggravate it, when 
inherited; and therefore children, bred and born with the predisposition, 
should, above all others, be defended against violations of hygiene; yet in 
this country they seldom receive such protection ; and sometimes this very 
infirmity, or, as it is called, delicacy of constitution, leads to a regimen and a 
destiny the opposite of what is proper. Thus the young daughter of a man of 
wealth is kept from out-door exercises, and the full and free respiration of 
pure and cool air ; and the daughter of a poor man, who shows a feeble con- 
stitution, is educated to be a teacher, or apprenticed to a seamstress, or placed 
in a factory, to stand nearly motionless for ten hours of the day, instead of 
being put from childhood at the hardest and heaviest in and outdoor labors 
of the family. The same is true of sons. He who inherits from wealthy 
parents a predisposition to consumption, is sent to school and college as early 
and unrelentingly, as though a long life were as certain a heritage as the 
family mansion. Exposure to the elements, extended walks, manual labor, 
athletic sports, and equestrian exercises are neglected, and when about to 
cross the threshold of society, he falls back into the grave. A farmer or me- 
chanic, in humbler circumstances, has a son whose slender muscular develop- 
ment and consequent feebleness, not less than his early intellectual and moral 
growth, are ominous of his fate; yet it is assumed that he will never be 
competent to the labors of the field, or the hard and heavy work of the 
smith, the mill-wright, or the civil engineer, and he is therefore put to some 
light, sedentary indoor occupation, or selected to be made the scholar and 
professional man of the family. Thus he is not only withdrawn from the 
line of life, on which the hope of escaping consumption rests, but placed 
under the very circumstances best fitted to bring it on. The melancholy 
results of these errors are to be seen in the numerous deaths of students, and 
young physicians, clergymen, lawyers, and other young persons of both 
sexes, which throughout our whole country swell the annual bills of mor- 
tality from consumption. 

Another error must be noticed. When the predisposition to tubercular 
disease is hereditary, it frequently shows itself in childhood by localizations 
in the eyes, the skin, the cervical ganglia, the joints, the mesenteric gauglia, 
or the brain ; which is too often regarded as an evidence that the lungs will 
never be attacked, and a diligent course of prevention is therefore neglected. 
Every child, thus assailed, is however liable to consumption after the age of 
puberty, and should be subjected to the hygienic discipline which has been 
pointed out. 

But the physicians of this country have little to encourage them to perse- 

* Book i. Part iii. Chap. iv. Sect. iv. 



910 THE PRINCIPAL DISEASES OF THE 

vering activity, in pressing on the people these or any other maxims of pre- 
vention. The shrine of Plutus-, Mars, Hymen, Apollo, every god and god- 
dess of the Pantheon, is thronged with warm-hearted worshippers, while 
Hygeria counts but here and there a reluctant devotee. No people are more 
prone to active medication when ill, nor any less given to the prevention of 
disease. He who might reverse these estimates would prolong the average 
term of human life throughout our extended Valley, and deserve a monu- 
ment by the side of that now rising to the honor of Dr. Jenner, for having 
prevented a different disease. 



SECTION III. 

PATHOLOGICAL CAUSES OF A TUBERCULAR DIATHESIS — INFIRMITIES OF 
PARENTS — CONTAGION — HEREDITARY TRANSMISSION. 

I. Various Diseases. — It is well known that consumption or scrofula 
occasionally occurs in the progress of other diseases, or follows upon them, 
and when this happens, they stand by their antecedence as its causes. But 
there is much room for fallacy in this matter. They might have accelerated 
the progress of a tubercular diathesis, or promoted the tuberculation of the 
lungs or lymphatic ganglia, in the predisposed, but not had an agency in 
generating the predisposition. 

1. At all times disorders of the digestive functions have been regarded as 
one of the causes of a tubercular diathesis ; but I am disposed to believe 
that this opinion, so venerable for its antiquity, and respectable for its dis- 
tinguished advocates in modern times, should be received with great limita- 
tion. Dyspepsia and tuberculation of the lungs are essentially diseases of 
the same period of life, beginning with the third septennial epoch, and 
greatly declining with the fifth. Now as there is no known incompatibility 
between the two morbid pathological states, we might expect sometimes to 
see them combined, but this no more proves that the digestive disorder pro- 
duces the tubercular, than that the latter occasions the former. But although 
often united, we quite as often observe each running on without the other. 
Thus every physician has seen dyspepsia continue for years, and even excite 
sympathetic bronchial irritation, without the supervention of consumption, 
and it is quite as common to see that malady begin, and go on to a fatal 
termination, without any previous or attendant dyspepsia. Still further, 
when that disease precedes consumption, it may be the effect of earlier tuber- 
cular ' action in the chylopoietic organs than in the lungs, or than pul- 
monary inflammation, without which we do not have consumption ; finally, 
an insidious hereditary predisposition may exist, and the dyspepsia act 
merely as an exciting cause. It may, however, be argued, a priori, that in 
dyspepsia a bad chyle is formed, which must of necessity affect both the 
blood and the solids, and thus generate a tubercular diathesis. Such a view 



INTERIOR VALLEY OF NORTH AMERICA. 911 

is plausible, and I am not prepared to deny its correctness, though I have 
not met with cases going to sustain it. 

2. Chronic disorders of the liver have likewise been thought capable of 
originating a tubercular diathesis. They may be said in all cases to include 
a sympathetic or secondary dyspepsia. Apt to carry a similar irritation into 
the lungs, they may be an exciting cause of the tuberculation of those 
organs in the predisposed, but I have no proofs of their being able to origi- 
nate a tubercular diathesis. The gloomy depression of innervation attendant 
on hepatic disorders, is certainly very different from the buoyant and excited 
condition of the same function in the tubercular diathesis, and might lead 
us to doubt the existence of any relation between them. 

3. Chlorosis sometimes precedes consumption, but before we assign to the 
former the power of generating the diathesis on which the latter depends, 
we must recollect, that they both occur in the same classes and about the 
same time of life ; that in the progress of a tubercular diathesis the cata- 
menial function is generally suspended, although no chlorotic symptoms 
might have previously occurred, and therefore when consumption follows on 
chlorosis, there may have been a previous tubercular diathesis producing 
the uterine derangement, or if that disorder occurred from other causes, it 
may have been but an exciting cause of the pulmonary tuberculation. That 
the functions of the lungs are often disturbed in chlorosis is certain, but the 
greater number of such cases terminate favorably, showing that tubercula- 
tion had not taken place. 

4. Bronchitis and influenza are often followed by consumption, and are 
then said to be its causes. But they are not capable of originating a tuber- 
cular condition of the general system, and can only be regarded as promo- 
ting the deposit, or the softening, of tubercle in the predisposed. 

5. Hemoptysis, in connection with consumption, should be viewed as 
an effect of deposited tubercle, and is therefore far removed from the causes 
which generate the diathesis on which the deposit depends. 

6. A long, slender or flattened chest, sometimes bent forward, giving 
great prominence to the scapuloe, is often spoken of as a cause of tubercular 
consumption. But this is an inversion of cause and effect. Such an 
osseous conformation is the result of a hereditary tubercular diathesis, and a 
sign that the individual will probably die of consumption. It may even aid 
in heightening the diathesis, and promoting the pulmonary affection by inter- 
fering with the full and healthy play of the lungs, but does not make it the 
cause of the tubercular predisposition. It must be admitted, however, that 
a badly developed respiratory apparatus may so far fail in absorbing and ex- 
creting power, as to favor a deterioration of the blood. 

7. Fevers, eruptive, typhous, and periodical, are sometimes followed by 
consumption. I am not prepared to admit their sufficient influence in the 
production of a tubercular diathesis, yet they may co-operate with other 
causes. When they occur in the predisposed, however, they unquestionably 



912 THE PRINCIPAL DISEASES OF THE 

promote both the development of the diathesis, and the deposition of tubercle 
in the lungs. Thus it is doubtless to the enfeebling and degrading influence 
of periodical fever, that we should, in part at least, ascribe the great preva- 
lence of consumption among the people of New Orleans, and the soldiers 
of our own Army in the South, and the British Army in the West Indies. 

8. Long-continued and debilitating medication is dangerous to those who 
are predisposed to consumption. The diathesis rises as the forces of the 
system sink, and although I would not admit this to a high place among the 
causes of an aboriginal tubercular diathesis, it deserves a high rank among 
the agencies which augment that condition and bring on a deposit in the 
lungs. 

II. Infirmities of Parents. — I concur in the opinion that the non- 
tubercular infirmities of parents are a source of the diathesis we are study- 
ing. It is probable that any infirmity which seriously affects the nutritive 
and other secretory functions of either parent, may have this effect. I sup- 
pose that tertiary syphilis in the father may be followed by a tubercular 
diathesis in his children, and I have seen a case in which fungus hematodes 
in that parent, seemed to generate the tubercular diathesis in two daughters. 
But the bad health or impaired constitution of the mother is doubtless much 
oftener to blame. Professor Miller, whose practice among the female sex 
has been extensive, informs me, that he has met with many cases of consump- 
tion which he could not trace up to any other cause. I shall not attempt to 
ascertain what ailments can impress on her offspring this predisposition ; but 
may refer to the period which precedes and follows the commencement of 
menstruation, and that in which the function declines into a final cessation. 

In regard to the first, we derive from the statistics of marriages and 
deaths some instructive data. For example, the returns of the State of 
Massachusetts, excluding Boston, show that between the ages of 5 and 10 
years, the mortality of the two sexes is equal ; but from 10 to 20, that of 
females is as 170 to 100 males. But we may safely conclude, that the 
equality continues to the age of puberty; and, therefore, that from the 
fifteenth to the twentieth year, the proportion of female deaths must be 
much greater than that which has just been expressed, that is, by calcula- 
tion, more than two to one. From 20 to 30, it is one and a half to one ; 
from 30 to 40, less than one and a third to one ; and from 40 to 50, equal. 
These numbers, thrown into a tabular form, stand as follows : — 





Deaths. 


Males. 


Females 


•OTC 


l birth to 15, . 


100 


100 


(( 


15 to 20, . 


100 


240 


tt 


20 to 30, . 


100 


150 


tt 


80 to 40, . 


100 


130 


tt 


40 to 50, . 


100 


100 



It appears from this table that a remarkable mortality among females 
occurs between the fifteenth and twentieth years, and that it continues high, 



INTERIOR VALLEY OF NORTH AMERICA. 913 

in comparison to that of males, up to the fortieth, but especially so to the 
thirtieth year. Now what is the relation of this mortality to marriage ? 
If we suppose it to begin at the fifteenth year, we have, according to the 
same returns between that and the twentieth, for males only 1-6 per cent, 
of the whole, but for females 27 per cent., or more than a fourth ; and by 
the twenty-fifth year, the males making only 45 per cent., the females rose 
to 73 per cent. Thus we see that nearly three-fourths are married before 
they are 25 years old ; and hence, a very large proportion of births occur 
during the period of great disease and mortality of females, the logical con- 
clusion from which is, that as far as a tubercular diathesis can have its 
origin in the bodily infirmities of parents, it comes incomparably oftener 
from the mother than the father. We are not discussing here the trans- 
mission of a tubercular diathesis from a parent in whom it exists, yet it is 
worthy of remark, that it prevails during this period in females over males 
at the highest ratio, rendering it probable that the causes which lead to 
this early mortality, impress the systems of the former with a proclivity to 
tubercular disease, which may manifest itself in the children of many who 
do not themselves die of that malady. Of these causes, premature mar- 
riage is unquestionably one of the most pernicious. To it, chiefly, we must 
ascribe the extraordinary mortality of females, compared with males, be- 
tween the fifteenth and twentieth year, when the proportion of marriages is 
as seventeen to one. It must be admitted, however, that after the tenth, 
and especially the fifteenth year, the mode in which girls are brought up is 
far less favorable to health, and the formation of a vigorous constitution, 
than that of boys. But on that very account early marriage is the more 
pernicious. 

That children, born after the commencement of those irregularities which 
precede the extinction of the catamenial functions, are very often infirm, is 
a generally admitted fact ; and that a tubercular diathesis may be among 
the infirmities is highly probable. The following case fell under my own 
observation. A married couple, entirely free from tubercular lesion, and 
belonging to families equally exempt, left three children in infancy from 
non-tubercular diseases, but reared seven to adult years. Of these, six 
were free from tubercular diseases, but the seventh, born after repeated 
attacks of exhausting menorrhagia, and not long before the final cessation 
of the catamenia, was, without any obvious cause, about the age of puberty, 
seized with scrofula of the cervical ganglia. I might dwell on this impor- 
tant branch of our subject much longer, but it has been so admirably illus- 
trated by M. Lugol, in his Researches on Scrofulous Diseases, as to render 
a more extended presentation of it unnecessary. 

III. Contagious Propagation. — The tubercular diathesis, whether 

hereditary or induced, has been held to propagate itself by contagion; but 

not till after tubercular suppuration of the lung has been established. This 

opinion, which dates back to the earliest ages of the profession, has chiefly 

vol. ii. 58 



914 THE PRINCIPAL DISEASES OF THE 

prevailed on the northern shores of the Mediterranean. In Great Britain 
and the United States, it has found but few advocates, though quite as few 
have flatly denied it. The question certainly ought to receive a final 
answer. I shall not attempt to give such an answer, but ask attention to 
the following facts and suggestions. 

1. From an early date, the milk of the ass and goat has been recom- 
mended in phthisis. It was thought to resemble that of woman, which, 
during the ages of medical credulity, would be most likely regarded as the 
most efficacious of the three. According to Borelli,* in the seventeenth 
century, the butter of woman's milk was sold as a remedy for consumption. 
We learn from Riverius,*]" that nearly 200 years ago, it was a practice in 
Italy to afford consumptives the opportunity of drawingthis milk directly 
from the breast, and he gives cases of its efficacy. Forty years after- 
wards, E. H. MullerJ declared that goat's milk was a " sovereign remedy" 
in some forms of phthisis, and then adds, that " woman's milk, sucked 
immediately from the breasts, without being exposed to the air, and the 
butter made of it, are preferable to any other." Each of these writers 
believed phthisis to be contagious, and Riverius cites a case of the supposed 
communication of the disease from a consumptive to his wet nurse. I have 
referred to these authorities for the sole purpose of showing, that it was 
when the practice of drawing milk from a woman's breast was most in vogue, 
that a belief in the contagious character of phthisis was most prevalent. 
Of all the modes of exposure to the breath of a consumptive, this was cer- 
tainly the most likely to promote an absorption of what exhaled from his 
unsound lungs ; for, in addition to the inevitable inhalation of his expired 
breath, it may not be too fanciful to say that the very evacuation from the 
breasts might have quickened absorption, as an increased secretion and 
excretion of it is well known to do. It is possible, then, that this mode of 
suckling the consumptive in the south of Europe has furnished us with a 
proof of the contagiousness of that malady which would otherwise have been 
wanting. 

2. There is abundant analogical evidence in support of the contagious 
propagation of this disease. Porrigo, hospital gangrene, erysipelas, chancre, 
malignant pustule, Egyptian ophthalmia, equina or glanders, variola, and 
measles, spread by purulent secretion, and why may not tubercle? The 
offensive breath of consumptives shows that morbid secretions are exhaled 
from their tubercular cavities, and there is certainly nothing to prevent 
their being absorbed by the lungs of others. Bichat, who spent so much 
time in his dissecting room, exhaled an offensive animal odor from his skin, 
showing that he absorbed largely from its atmosphere. 

3. I do not doubt that tubercular pus possesses active properties. It is 
well known that the bronchial tubes leading from a tubercular cavity, become 

* Young's Prac. and Histor. Treat, on Cons. Dig., London, 1815, p. 174. 

t Ibid. p. 176-7. % E. H. Muller Abridged, p. 254-5. 



INTERIOR VALLEY OF NORTH AMERICA. 915 

inflamed under the expectoration of its contents; the escape of the same 
contents into the cavity of the pleura, produces immediate inflammation ; 
and, lastly, I have been assured by a gentleman of accurate observation, who 
in the country often sat in front of his door while in the expectorating stage 
of phthisis, that when the domestic fowls swallowed his sputa, as they some- 
times did, the effect was vertigo, under which they would fall and lie for 
some time on the ground, before they could walk away. 

4. "Without referring to books, I may state that many of our own physi- 
cians have met with apparent contagious propagation ; generally where it 
would be most likely to occur, that is, in the conjugal state ; and therefore 
under circumstances the least equivocal, seeing that it does not often happen 
that both the parties belong to consumptive families. This very day I was 
informed by Professor Miller, that in his (extensive) practice, he has repeat- 
edly seen wives attacked with phthisis soon after nursing their husbands 
through that disease, et vice versa. This I have myself often witnessed, 
and may mention a single case which occurred long since. A newly mar- 
ried woman, having an hereditary predisposition, fell into phthisis soon after 
the birth of her first child ; while at the breast it became affected with the 
same disease, which, I admit, might have been entailed upon it. Being 
poor, the family inhabited a single room, and the husband was the sole atten- 
dant on both, with whom he also lodged. Soon after their death, without 
having any known predisposition, he was seized with the same malady, 
which proved rapidly fatal. The following observation was communicated 
to Ae by Dr. Carroll. The daughter of a man who had a family predisposi- 
tion to consumption, returned home from school with that disease. Her 
mother, a robust woman, nearly fifty years of age, and entirely free from 
hereditary taint, nursed her without intermission, and slept in the same bed 
with her. • Soon after she died, the mother was seized with the same malady, 
and died also. 

With such facts before us, we may, I think, regard it as highly probable 
that one of the causes of a tubercular diathesis is the continued or frequent 
inhalation, and the slow absorption of gaseous or suspended tubercular 
matter, exhaled by a phthisical patient. 

5. As a general fact, in all cases of contagious propagation there is a 
period of incubation, during which no sign or consciousness of disease may 
exist, and the duration of this period is exceedingly various. In small-pox 
it is sometimes sixteen or seventeen days, and in hydrophobia as many weeks, 
perhaps even months. Now, we have only to admit that the tubercular virus 
has its own and a somewhat protracted stage of incubation, to understand 
how it might be operative in the production of the disease in others, and 
yet be quite overlooked; the attack being ascribed to various agencies 
which, at most, might be only exciting causes. Nor can we raise a valid 
argument against this hypothesis from the fact, that many who are exposed, 
do not suffer ; for this, from idiosyncrasy, happens in the case of all conta- 



916 THE PRINCIPAL DISEASES OF THE 

gious diseases. It may be, moreover, that the susceptibility to this conta- 
gion, admitting its existence, is greatly diminished in more advanced life ; 
for this is apparently the case with some other contagions ; and as consump- 
tion and scrofula are both diseases of early life, we may suppose the consti- 
tution in that period most vulnerable to the action of the assumed virus; 
which suggests the propriety, while this matter is still subjudice, of ex- 
cluding the young from any long-continued and intimate personal inter- 
course with the sick. 

The greater prevalence of consumption in cities than the country may fur- 
nish an argument in favor of its contagiousness, for in the former the popu- 
lation is more compact, and the ventilation less perfect. 

We may perhaps find in the hypothesis of contagion, an explanation, in 
part, of the prevalence of consumption in the warm climates. They may 
favor the greater volatilization of the tubercular excretion, which may 
require for that condition a higher temperature than some other contagions. 

A disbelief in the contagiousness of consumption is highly favorable to 
the spread of that disease, if it can really be propagated in that mode, inas- 
much as in private practice, and both civil and military hospitals, no mea- 
sures of prevention are employed. 

Finally, when we look at the statistical tables in the first section of this 
chapter, and see that the mortality from consumption is not as we had too 
hastily assumed, inversely to the mean temperature of climate, but appa- 
rently the opposite, we are required to look for other causes, and who can 
say that one of them may not be contagion ? In conclusion, I would c#m- 
mend this subject to the attention of the profession, especially in the middle 
and southern portions of our Valley. 

IV. Hereditary Transmission. — However produced originally, we 
know that a tubercular diathesis may be transmitted from parent to child. 
At birth it is in general merely a predisposition or proclivity, but in common 
with other observers, I have seen deposits of tubercular matter in newly- 
born infants who have died of other maladies, and they had the appearance 
of having been made by a lesion of formative nutrition. In the opinion of 
M. Lugol, many abortions are referable to this cause, the nutrition of deve- 
lopment being arrested. In other cases, the child is brought forth with fully 
established consumption (as it is sometimes with small-pox), in the progress 
of which, it exhibits the aspects of thought and feeling which belong to 
children whose ages, compared with its own, are as years to months. In one 
case of this kind, the mother, as yet apparently in good health, was seized 
with fatal consumption soon after the death of her infant. No proof of 
hereditary propagation could be more conclusive ; for no other cause than 
the tubercular diathesis of the mother could have existed. She had borne 
two children previously, both of which were scrofulous. At the time of 
their births also, she was, to all appearance, in good health. It would seem 
that when her diathesis was less developed, her offspring were affected in a 



INTERIOR VALLEY OF NORTH AMERICA. 917 

milder way ; when it had become so great that tuberculation of the lungs 
had, or was about to begin, her child was born with consumption. In this 
case there was no obvious external cause for her diathesis, nor for that of 
her scrofulous children ; but her own, like theirs, was hereditary. 

What proportion of all cases of consumption and scrofula depend on heredi- 
tary transmission, will perhaps never be known. The ratio is, of course, 
greatest where the external, pathological, or other occasional causes of that 
diathesis, are least operative, the prevalence of the disease being the same. 
This much we may affirm, that if the tubercular diathesis were to lose its 
place among the hereditary predispositions; and we had no cases of con- 
sumption but those produced, ah initio, by the causes we have reviewed, 
that disease would no longer be, as it now is, the greatest of all single causes 
of mortality. 

In attempting to decide in certain cases whether they should be referred 
to entailment by parents, or to other causes, we are liable to fall into error, 
and generally, perhaps, to underrate the influence of transmission. Thus, 
if we see an individual, while exposed to a rigorous climate, or following 
some occupation of suspicious effect, become the victim of consumption or 
scrofula, we are apt to ascribe it to that influence, instead of hereditary pre- 
disposition ; when, at most, it might have been only an exciting cause. 
Again, as it is not necessary to the transmission of a tubercular diathesis, 
that the parent shall labor under actual consumption or scrofula, children 
may, by hereditary attaint, be attacked with either, while both parents seem 
healthy j and then the malady is generally ascribed to external or non- 
hereditary agencies. A gentleman in this city had a wife who died of con- 
sumption, and all her children but one fell a victim to that disease, which, 
of course, was supposed to be derived from her. When, however, he had 
reached his 60th year, he himself died of a pulmonary disease, which I ascer- 
tained by post-mortem inspection to be tubercular. Now, it is obvious, 
that if he had married a woman free from that disease, the children might 
have derived a predisposition from him, and, had he died of any other 
malady at an earlier age, their attacks might have been ascribed to external 
or producing causes, instead of hereditary transmission. This gentleman, 
in early life, had been a land surveyor in the wilderness, which had doubt- 
less warded off the disease; and his case may stand as the representative of 
many others, in which a proper hygiene defers the attack to the latter part 
of life, or nullifies the diathesis altogether. I look upon this diathesis as so 
intimately connected in origin with adolescent nutrition, that I cannot avoid 
believing, when a tuberculization of the lungs occurs after the 50th year, 
there was either a congenital predisposition, or a proclivity created during 
the subsequent stages of growth. A large proportion of those who are said 
to die of consumption in old age, are undoubtedly the victims of chronic 
bronchitis ; but if they had a slight tubercular taint, that inflammation 
might produce a limited tuberculation of the lungs. 



918 THE PRINCIPAL DISEASES OF THE 

In some instances, we may deny or doubt the hereditary origin of con- 
sumption, from the absence of that disease in parents, an absence which may 
continue through life. But is it not true, that hereditary maladies may 
pass over children, and attack grandchildren ? M. Lugol, in his able work 
already quoted, seems to deny this, yet he admits all that is necessary, the 
occurrence in childhood of some scrofulous affection, which had been arrested. 
Thus parents may have a tubercular diathesis, which may not lead to con- 
sumption ; and still that disease, or a strumous affection, may occur in their 
offspring. I have certainly met with many instances of both consumption 
and scrofula in children whose parents were free from those diseases, but 
their brothers and sisters were not. I know a gentleman, now nearly 70 
years old, who has always been free from any form of tubercular disease, 
and his wife equally so; yet several of their children, when young, had 
severe and most protracted attacks of scrofula, in the skin of the face, the 
eyes, or the mesenteric ganglia. Among his brothers and sisters, there was 
both scrofula and consumption. I have observed the same thing in cases of 
insanity. A mother, now advanced in life, and always of sound mind, has 
a son who is foolish, and two others insane — one of her brothers was idiotic. 
We are not, then, to affirm of any instance of tubercular consumption, that 
it has not arisen from transmission, merely because the parents may have 
shown no local tuberculations. 

When, as sometimes happens, both parents are tubercular, the offspring 
can scarcely escape, yet all do not necessarily perish. When one parent 
only has the diathesis, the children which most resemble that parent are in 
the greatest danger. A child may for a while resemble one parent, and 
then gradually come to resemble the other. Should this change be in the 
direction of the tubercular parent, disease of that kind is in general inevi- 
table ; but when it takes the direction of the other, notwithstanding the 
child may have shown evidences of tubercular diathesis, it may finally 
escape. This is called outgrowing the disease. If some children did not 
inherit the constitution of one parent, some that of the other, if all combined 
the qualities of both parents, the tubercular diathesis would much more 
frequently show itself in the offspring, and the mortality from that source 
be still greater than it is. 

There are not, I think, any facts going to show, that the most perfect 
exemption from tubercular taint, with the highest health and vigor in one 
parent, is a guarantee against a tubercular taint from the other. When the 
parties are thus assorted, and especially when the predisposition exists in 
the wife, the first children are perhaps most likely to escape ; for the func- 
tion of reproduction in the female contributes to the development of the dia- 
thesis; and, as we have already seen, may perhaps, when prematurely 
exercised, originate it. Hence there is no other disease which so intimately 
connects itself with marriage. M. Lugol, writing in a country where the 
idea of governmental interference in private affairs has a breadth unthought 



INTERIOR VALLEY OF NORTH AMERICA. 919 

of in the United States, suggests, that those who are predisposed to this 
and other fatal hereditary diseases, should be prohibited from marrying. It 
is quite certain, that they ought not to marry ) but no restraints can be 
imposed but those of moral suasion, which, if earnestly pressed upon the 
young by physicians and parents, might to some extent do good ; but I am 
sorry to say, that very little is ever attempted by either. Parents see their 
children contract matrimonial alliances without informing themselves on 
this point, or even with a full knowledge of the existence of a predisposi- 
tion to consumption. When they know that a cherished daughter has that 
infirmity, they see her married at 16 or 18, with no more apprehension than 
if she were 25, and had no known predisposition. The fact that she will 
probably die after the birth of her first or second child, leaving it a sickly 
charge on their hands, makes no impression on their hearts. Young physi- 
cians, also, who are strongly predisposed, marry as early and unhesitatingly 
as if they enjoyed the finest constitutions; and, in choosing wives, seem 
never to inquire into their predisposition to this or any other disease ; or, 
knowing the worst, do not find in it a reason for restraining their impulses. 
This indifference to the future, bad enough in any state of society, is pecu- 
liarly deplorable in ours, where early marriage prevails among all classes. 
"Without insisting that those who might entail a tubercular diathesis on 
their offspring should never marry, I may urge, that they should not marry 
precociously. We have seen the great mortality of consumption between 
the 15th and 30th years of life. Taking the sexes together, consumption 
destroys one-half of all who die from every kind of disease in Massachusetts, 
between those dates ; and the number, compared with the population, is 
still greater in our cities. Now, if all who married during that period had 
deferred it, many of them would have escaped it altogether, and none would 
have left children to die of the same malady, before or after having trans- 
mitted the fatal taint to another generation. 

The continued influx of European immigrants, and the unsettled and 
migratory habits of our native population, carry the predisposed into 
every climate and locality of our great Valley. Thus, we are deprived 
of the opportunity of studying the influence of external causes in the 
production of a tubercular diathesis. When a family leaves the sea- 
coast of New York or New England to settle on the dry and rolling prairies 
of Illinois or Iowa, it may bring, in some of its members, a predisposition 
which may be ascribed to the climate of the new home ; another may carry 
the same predisposition from the centre of Pennsylvania to the shores of 
Lake Erie, and when the disease becomes developed, the humid atmosphere 
of the inland coast may be blamed for what would have occurred if no re- 
moval had been made. But the greatest impediment to successful inquiry 
is produced by the incessant emigration from North to South, which is pro- 
moted by the general mortality which prevails in the latter, and by the 
popular opinion that the predisposed should seek a more southern residence. 



920 THE PRINCIPAL DISEASES OP THE 

Taking with them a proclivity, which higher temperature cannot correct, 
they intermarry with the native population, and thus extend the prevalence 
of the disease, leaving but little opportunity for the etiologist to compare the 
colder and hotter regions in their relation to the tubercular diathesis. 

I shall conclude this interesting branch of our inquiry by a reference to 
the great mortality from consumption among the black troops of the West 
Indies. It amounts, according to our tables, to one out of every one hun- 
dred and thirteen yearly, while that of the white troops, serving in the same 
region, is only one in a hundred and sixty, although they grew up in Eng- 
land. One cause of this high ratio, is, I suppose, the long-continued inter- 
marriage or cohabitation of the same families on the large plantations, 
together with the early age at which the function of reproduction begins to 
be exercised. I find an evidence of this in the fact, that in the city of 
Charleston, where, as I know from observation, the moral and social condi- 
tion of the blacks is nearly the same with that of the domestics and the 
poor laboring classes of the more northern cities, their liability to consump- 
tion is not greater than that of the whites. Why, then, but for the causes 
I have mentioned, should it be fifty per cent, greater in the West Indies ? 
We cannot ascribe the difference either to duties or modes of living, as 
these are the same for both kinds of troops, — a part of it may be attributed 
to innutritious diet in childhood ; but many of the white soldiers suffered 
equally from that cause when children, and I am, on the whole, compelled 
to believe in the mischievous effects of the practices to which I have re- 
ferred. The great prevalence of consumption among the blacks in the 
West Indies is the more remarkable from the fact that their European 
ancestry are almost exempt from that malady. According to Dr. Lugenbeel, 
it prevails but little in Liberia, lat. 6°— 7° N. ) and I have been informed 
by the Rev. Mr. Bushnell, who has spent eight years in missionary labor on 
the banks of the Gaboon, under the equator, that in all that time he had 
seen but one case of consumption, the subject of which was a young woman, 
showing how pre-eminently the tubercular diathesis belongs to her sex and 
age. 

In closing this long chapter on the etiology of a tubercular diathesis and 
the production of consumption by tuberculatum of the lungs, it may be well 
to recapitulate its more important points. 

1. So far from being peculiar to cold and variable climates, this diathesis 
originates in all latitudes, from the higher portions of the temperate zone, 
where the mean heat is 40°, with sudden and violent changes, to the 
equator, where it rises to 80°, and presents but few variations. It even 
seems to increase as we travel south ; but as we have made consumption its 
exponent, we should rather say, that its issue in that disease is more fre- 
quent in the South than the North. Rejecting the evidences of greater 
prevalence in the South, as incompatible with popular opinion, it would be 
unwarrantable to declare it more frequent in the North, and we are, there- 



INTERIOR VALLEY OP NORTH AMERICA. 921 

fore, brought to the conclusion, that its connection with climate is not of 
that intimate kind which has been asserted, and that additional data are 
necessary to a final decision. 

2. Consumption prevails more in our cities than in the country, showing 
either a greater prevalence of the tubercular diathesis there, or a more ener- 
getic action of the causes which promote the deposit of tubercle in the lungs. 
Among the former we may recognize insufficient exercise, luxurious, or 
innutritious diet, defective clothing, confined lodgings, unventilated dwell- 
ings, and different chronic diseases ; among the latter, the inhalation of an 
air loaded with mechanical impurities. 

3. The causes of a tubercular diathesis exert their most pernicious influ- 
ence during the period and upon the function of adolescent nutrition, which 
they enfeeble and degrade. But the causes which promote the deposition 
of tubercular matter in the lungs, may act at any time. 

4. There is some reason for believing that tubercular consumption may 
be communicated by contagion. 

5. But the immediate cause of its extensive and somewhat equal preva- 
lence, under climatic and other circumstances widely different, is hereditary 
transmission of a peculiar diathesis. This proclivity is ingravescent, and 
may end in consumption independently of all co-operative agencies; yet it 
may be promoted by many, of which two of the greatest are deficient exer- 
cise and premature marriages. On the other hand, it may be retarded, if 
not subdued, by hygienic regulations. 



CHAPTER XIX. 

TUBERCULAR PNEUMONITIS CONTINUED: DIAGNOSIS OF THE EARLY 
STAGES, PATHOLOGY AND TREATMENT. 



SECTION I. 

EARLY DISTINCTIVE SYMPTOMS AND SIGNS OF PHTHISIS. 

I. I do not propose to add an inferior to the many excellent histories of 
the progressive symptomatology of this disease which are now before the 
profession, but limit myself to a brief account of its distinctive diagnosis. 
In the preceding chapter incidental reference has been made to the physio- 
logical and psychological aspects of those who are predisposed to this 
malady, and in proportion as they are present, we may suspect the existence 
of incipient phthisis when signs of pulmonary irritation exist. Thus, if the 
patient have (what I may call, without misleading any one) the tubercular 



922 THE PRINCIPAL DISEASES OP THE 

temperament, and is between the age of eighteen or twenty, and thirty or 
thirty-five, the slightest symptoms of pulmonary disorder should excite ap- 
prehension, for prima facie, they denote a tuberculation already com- 
menced; or if not, they indicate the existence of some other primary or 
sympathetic affection of the lungs, which, allowed to continue, may promote 
the deposit of tubercular matter. The symptoms most pathognomonic of 
that earliest stage are an habitual, dry, and rather hacking cough, often in- 
creased for a short time on lying down, especially in a cold bed ; an increased 
susceptibility to changes of weather, leading to frequent, though not neces- 
sarily, violent attacks of pulmonary catarrh, attended with transparent, 
mucous expectoration ; diminished strength, and a shortness of breath on 
running, or any other considerable muscular exertion ; in many cases, con- 
siderable increase in the frequency of the pulse, which is much promoted 
by active effort, its force and fulness not being, however, augmented in a 
corresponding degree; finally, occasional wandering pains in the lateral 
walls of the chest, more especially in the subscapulary muscles, and the sub- 
jacent intercostals. I have often been consulted by young men for a pain 
in the region of the sternum. This is generally a neuralgic aching of the 
periosteum of that bone, or the laminse of the anterior mediastinum, and 
does not forebode tuberculation of the lung. 

The relation between the symptoms and the first physical signs is not 
always the same. Thus it often happens that a first examination scarcely 
reveals any anatomical lesion in one patient, while in another they are well 
developed, although the symptoms may neither be more violent, nor have 
lasted longer. These well-known signs are, first, diminution of resonance 
below, underneath, or above the clavicle. In some cases this is so slight 
that nothiDg but the most careful comparison of the two sides of the chest 
will enable us to detect it, and if the tuberculation of both apices should 
be going on at the same time, we may close the examination without coming 
to a satisfactory conclusion. In making percussion, we must bear in mind 
that the general thinness of the muscles, and deficiency of adipose tissue 
increase the resonance of the chest, and, therefore, that a hollowness of 
sound, which might be normal when heard through thicker parietes, may in 
reality be below that which should be heard under the thinning of the tho- 
racic walls of such a patient. On resorting to the stethoscope or unarmed 
ear, the respiratory sounds in the upper part of the lung are loud, rude, and 
bronchial, by which the vesicular murmur is partially or entirely obscured. 
Here again, however, it is advisable to inspect in the same manner the other 
lung, and to extend the observation downward over both till we reach a line 
below which the two are alike. The observations, moreover, should be 
made both behind and before. In regard to the voice, its resonance in the 
bronchial tubes is conducted through the partially solidified lung, so as to 
give a bronchophony, which might always be mistaken for the resonance in 
a cavity, if it were not heard equally over every part of the affected apex. 



INTERIOR VALLEY OF NORTH AMERICA. 923 

The symptoms and signs thus briefly enumerated, may, I think, be taken 
as diagnostic of the early stage of phthisis. There are others, however, not 
to be overlooked. In some cases the mucus which is sparingly expectorated 
is not merely streaked with blood, but that fluid predominates, and may 
even amount to a moderate ha3moptysis. But a symptom which occurs still 
oftener, is a congestion, or very subacute inflammation of the fauces, some- 
times extending to the larynx, and producing a feeling of dryness, with 
weakness, hoarseness, or flatness of the voice. \ In the female the catamenia 
are in general reduced in quantity or suspended ; pregnancy seems to miti- 
gate — almost to arrest all the symptoms — after delivery, however, they ad- 
vance with increased rapidity. 

Through an indefinite period, in many cases to be measured by months, 
others rather by weeks, although the heart may beat with unnatural fre- 
quency, there is little or no abnormal heat of skin ; and the patient cannot 
be said to have fever; that condition is however impending and inevitable. 
It generally shows itself, by an almost imperceptible rise ; but sometimes 
by a violent change of weather may be suddenly awakened into sustained 
activity, with a pulse of considerable resistance ; the respiration becomes 
hurried, the cough more troublesome, the mucous expectoration greater, the 
pains about the chest more acute, and the subclavicular region becomes tender 
under pressure. There is now a true tubercular pneumonitis j and it gives 
such an impulse to the deposit of tubercles, that the physical signs become 
rapidly more developed. In many cases the fever is neither ushered in by 
a chill, nor followed by perspiration ; yet in others both these phenomena 
occur before the expectoration of pus commences, though not perhaps before 
its formation. 

With this brief diagnostic statement as a standard of comparison, let 
us proceed to inquire what pathological states may either simulate or 
obscure it. 

II. Chronic Subacute Inflammation, or Congestion of the 
Pharynx. — Inflammatory congestion of the membrane covering the tonsils, 
the palate, and the pharynx, may excite a cough. The cedematous swelling 
and lengthening of the uvula especially produces that effect. As this cough, 
like that attendant on the forming stage of tubercular pulmonitis, is accom- 
panied by little expectoration, the question will arise in every case, whether 
the throat affection is primary or secondary; or perhaps I should rather 
say non-tubercular or tubercular. The decision is not always easily made. 
Other early evidences of a tubercular deposit being present, the affection 
may be suspected, especially if the throat should be enlarged by the attenua- 
tion of its walls. The state of the pulse may be relied upon as far as a single 
symptom can go. In the non-tubercular erythema, the pulse does not rise 
in frequency above the natural standard ; exercise does not excite it more 
than in health ) nor does muscular effort accelerate the respiration beyond 
what is normal. In some cases the throat affection is sympathetic of dys- 



924 THE PRINCIPAL DISEASES OP THE 

pepsia, and hence the state of the stomach should be ascertained. If the 
irritation of an elongated uvula should keep up the cough, the removal of a 
portion will be followed by mitigation of that symptom. Finally, percus- 
sion and auscultation should be employed, and if the thoracic sounds should 
be strongly marked either way, the diagnosis may be declared. Should 
they be equivocal, the decision must be made by the symptoms, when it 
will be safest for the patient, and best for the reputation of the physician, to 
predict possible tuberculation. 

III. Chronic Laryngitis. — This is often present in the state of the 
tonsils and pharynx which has been described ; but it may exist alone. It 
maybe a simple non-tubercular hyperasmia, or ulceration of the mucous mem- 
brane, or the result of early tuberculation of the part, from sympathy with the 
lung in the incipient stages of its tuberculation. If the patient have had an 
attack of acute laryngitis, or of scarlatina, there is less ground of suspicion of 
tubercular deposition. The same if his aphonia have come on suddenly; the 
same if his pulse be natural in frequency. If he have been a public speaker, 
the case, prima .facie, may be regarded as simple. I have seen one case in 
which dilatation of the heart was accompanied by reduction of the voice to 
a whisper; thus we see it maybe secondary to other affections than those of 
the lungs. The frequency of this laryngeal disorder, in tubercular pneumo- 
nitis, should, however, lead to its being viewed with apprehension ; and I 
know of no certain reliance but on the pulmonary physical signs. If they 
should be distinctly normal after the affection of the larynx has continued 
for some time ; and the hereditary predisposition of the patient should be 
little marked, the apprehension of pulmonary phthisis may be put away. 
Several years since two clergymen called on me as they were returning from 
the tierras calientes of Mexico; both had laryngeal disease, and their symp- 
toms were on the whole much the same. On examining their chests, how- 
ever, I found the signs of pulmonary tuberculation absent in one — present in 
the other. The latter died of phthisis a few months afterwards, but the 
former is still alive, and enjoys good health, being nearly free from every 
kind of laryngeal and pneumonic difficulty. 

IV. Tracheal Ulceration.— I have seen two or three cases (not verified 
hjffpost-mortcm inspection) of what seemed to be tracheal ulceration. There 
was cough with occasional expectoration, and a feeling of soreness in the 
trachea, increased by pressure. The larynx was not affected. The mode- 
rate state of the pulse and the absence of the physical signs of pulmonary 
tuberculation will justify the conclusion that the lungs are unaffected. 

V. Chronic Bronchitis. — The subjects of this affection are of a different 
anatomy and physiology from those most liable to phthisis. They expe- 
rience less emaciation than belongs to the early stages of that malady. Their 
expectoration is more copious. The pulse is slower. Under percussion the 
apices of the lungs sound well ; and the stethoscope reveals, not as in the 
foregoing maladies, a natural respiratory murmur, but a mucous or muco- 



INTERIOR VALLEY OP NORTH AMERICA. 925 

sibilant rattle. Finally, hot or warm weather mitigates the bronchial much 
more than the tubercular affection. 

VI. Hepatization op the Lung. — A dry cough, frequent pulse, and 
dyspnoea under exercise accompanying this affection, but an acute pneumonia 
has generally gone before ; and if seated in the lower part of the lung, the 
conclusion is against tuberculation, for that state would (probably) have 
invited the inflammation into the upper part of the organ. The physical 
signs are here of much value. The absence of abnormal sounds in the apex 
with the presence in the base of dulness and bronchial respiration, may be 
regarded as conclusive ; if, however, the inflammation should have been 
seated in the apex of the lung, the sounds become identical with those of 
tubercular induration ; and have no distinctive character. If symptoms of 
incipient phthisis should be present, the decision should be in that direction. 
Much of the induration may, it is true, be the effect of common inflamma- 
tion ; but how much we cannot tell, and the fact of its attacking that por- 
tion of the lung is suspicious. 

VII. Chronic Pleurisy. — There may be cough with moderate expecto- 
ration ; a frequent pulse and dyspnoea, increased by exercise ; but in many 
cases an acute pleurisy has preceded. The patient prefers to lie on the un- 
sound side, or avoids lying on the sound. Our chief reliance, however, 
might be on the dulness of the lower part, if not the whole of the affected 
side, and the ^ absence of respiratory sounds, with a normal condition of the 
sounds of the apex, if it be not surrounded by the effused fluid. At a sub- 
sequent period such a patient may present himself to the physician com- 
plaining of a dry cough, more or less pain or uncomfortable feeling in his 
side, and dyspnoea under active effort ; the same symptoms, moreover, may 
follow on a pleurisy so transient as not to have distended the sac with 
effused fluid, to be afterwards absorbed. In both cases, the essential diffi- 
culty results from permanent adhesions by false membrane. The sounds of 
the affected side may be normal. Under such circumstances, the collapse 
of the side after great effusion, and the freedom of the apex of the lung 
from all abnormal sound will guide to a correct diagnosis. 

VIII. Spasmodic Asthma. — It is only in the forming stage of this 
malady, that the symptoms which characterize it can be at all confounded 
with those of incipient phthisis. But the dyspnoea is distinctly paroxysmal, 
and the cough is not habitual. In the paroxysm, the difficulty of breathing 
is much greater than any which attends early tuberculation of the lung ; 
which, moreover, sounds well under percussion. A resort to the stethoscope 
discloses sibilant or chirping and mucous rales over the whole of both lungs, 
which cease with the paroxysm. Thus the differential diagnosis is not 
obscure. 

IX. In addition to these common affections of the lungs, we must recol- 
lect that the aerial passages are occasionally the seats of polypous, fibrous, 
warty, or epithelial, and sometimes malignant tumors, and that the lym- 



926 THE PRINCIPAL DISEASES OP THE 

phatic ganglia of the posterior mediastinum are subject to melanosis, all 
of which establish a pulmonary irritation, with cough, and sometimes expec- 
toration. As we know not the diagnosis of these excrescences, we are 
thrown upon the incipient phthisical symptoms as our only diagnostic 
resource. 

X. Affections of the Heart. — These, whether functional or organic, 
never fail to excite a cough, generally dry and hacking ; a certain degree of 
dyspnoea, increased by exercise ; more or less pain, and increased frequency 
of pulse. The patient generally mistakes these for a pulmonary affection ; 
and, I may (reluctantly) add, not a few physicians fall into the same error. 
I know a lady, enjoying good health, except an occasional recurrence of the 
symptoms just recounted, who, five years ago, was declared by her physician 
to have incipient consumption, and a visit to the South was even spoken of. 
Having previously examined her chest, I felt assured (without any overween- 
ing self-confidence in my skill), that her disease was not pulmonary, and time 
has established that diagnosis. It is indeed chiefly by percussion and aus- 
cultation that this piece of distinctive diagnosis is to be made out. Until 
the malady of the heart is far advanced, the lungs may remain intact, and 
the parts which are usually the seats of tuberculation will continue to emit 
natural sounds, while those of the heart are abnormal, according to the 
nature of the lesion. Among the pulmonary affections from disease of the 
heart most deserving of attention after those I have mentioned, is haemop- 
tysis, which, however, does not occur till the cardiac lesion has existed for 
some time, and is well declared; and topical pleuropneumonia from the ex- 
tension of pericarditis to the neighboring portion of the lung has taken 
place. This, however, leaves the apex uninjured, while the characteristic 
crepitant rattle can be heard in the affected part, if not obscured by the 
loud sounds of the heart. 

XI. Spinal Irritation. — What is called spinal irritation may occasion 
functional disturbances of the lungs simulating the first symptoms of phthisis. 
The heart generally participates in this influence, and hence there is a fre- 
quent pulse. The thoracic muscles are often the seat of transient pains. 
The cough is unexpectorating, but no longer hacking; on the contrary, 
often violent and paroxysmal. It may be suspended by narcotics. The 
apices of the lungs emit only normal sounds ; and in general there is spinal 
tenderness. When pressure is made upon the morbidly sensible spot, 
paroxysms of cough are sometimes excited. In deciding on the existence 
of spinal tenderness, we must not forget that the portion of the column 
which lies between the lower ends of the scapulae, are in health more sen- 
sible to pressure than other portions of the spine, as the epigastrium is more 
sensitive than any other portion of the median line in front. It is probable 
that chronic affections of the brain may sometimes disorder the'lungs through 
the medium of the pneumogastric nerves. I recollect many years since, a 
child that was affected with a constant, dry, and rather spasmodic cough, 



'INTERIOR valley OF NORTH AMERICA. 927 

unaccompanied with much fever. I could make nothing of it but a laryn- 
geal or pulmonary affection. It gradually declined in strength, and at 
length became paralyzed on one side with strabismus, and dilated pupil; 
dying with the closing though not the antecedent symptoms of hydrocephalus. 
It is likely, however, that this was a case of low tubercular affection of the 
brain, and that the lungs were in the same state, but a post-mortem inspec- 
tion was not permitted. 

XII. Dyspepsia. — Morbid sensibility of the stomach and bowels, or mild 
chronic gastritis, with acidity, flatulence, and epigastric tenderness on pres- 
sure, affects both the heart and lungs. The former becomes irritable, with 
paroxysms of palpitation, A cough, sometimes hacking and sometimes 
spasmodic ensues. Occasionally the bronchial membrane takes on increased 
secretion, and expectoration occurs. There is often a considerable degree of 
pharyngeal congestion with increased secretion of mucus, and the tongue is 
foul, with a dirty, moist fur, especially on the posterior part. The inter- 
costal muscles in some cases partake of this sympathy, and are more or less 
the seats of wandering pains or aches. The distinctive diagnosis of such a 
case is to be found in the presence of the gastric symptoms, which, in the 
highly developed tubercular diathesis are rare, yet not always absent. But 
the physical signs may protect us from error. As long as the sounds of the 
lungs continue natural we may assign the pulmonary symptoms to the 
stomach as their pathological cause. We must not forget, however, that 
the era of dyspepsia and tuberculation are the same, that bad modes of 
living may induce the former in a constitution prone to the latter, and that 
its influence on the lungs might be to promote the deposit of tubercular 
matter; a search after which should be frequently made by percussion and 
auscultation. Cases of this kind, in which the morbid condition of the 
stomach acts as the exciting cause of pulmonary tuberculation, constitute 
the dyspeptic consumption of Sir "Wilson Philip. 

XIII. Hepatic Disorders. — These are well known to excite cough, some- 
times dry and short, at other times accompanied with bronchial expectora- 
tion. They also give a frequent pulse, and pains or achings not only in 
the shoulder, but frequently on the right side down to the pelvis. Mean- 
while the liver itself may not be the seat of pain, and if no jaundice exist, 
the affection of the lungs may be regarded as primary, and if so most likely 
tubercular. When the lungs are examined in such a case, no unnatural 
sounds are heard, and a deep inspiration can be made without exciting cough, 
as in the case of spinal irritation and gastric disorder. The patient more- 
over prefers to lie on his right side, and has a dyspeptic state of stomach, 
with bowels alternately affected with diarrhoea and constipation ; finally, his 
complexion is generally turbid or sallow, the opposite to that in tubercula- 
tion, and his urine is yellow, if his eyes and skin should not be jaundiced. 

XIV. It is unquestionable that a certain degree of haemoptysis is fre- 
quently attendant on tuberculation of the lung. It seems not to have a 



928 THE PRINCIPAL DISEASES OF THE 

dynamic but merely a mechanical cause. It is therefore, I think, most fre- 
quent when the deposition proceeds at such a rate that the remaining chan- 
nels have not accommodated themselves to the transmission of the blood, 
which the solidified portion of the lung can no longer receive, but it may 
be that the vascular parietes in that part have become weakened, and 
liable to rupture. We all know that these hemorrhages were once regarded 
as the cause of consumption. Thus an association of ideas suggests that 
malady whenever we have haemoptysis. I have already mentioned its occur- 
rence in maladies of the heart when it does not indicate tuberculation. 
In men of a sanguine temperament and plethoric habit it sometimes occurs 
in profusion, and is not followed by phthisis. It is a simple hemorrhage 
like that of epistaxis in earlier life, though frequently from larger vessels. 
The previous condition of the patient, and the absence of abnormal sound 
in the usual seats of tubercular deposit, will guide us to a correct diagnosis. 
In women non-tubercular pulmonary hemorrhage is more common than in 
men, being frequently periodical and vicarious. In such cases, the cata- 
menia are suspended, as they are in early phthisis, and thus the difficulty 
of the diagnosis is increased. Cough and expectoration moreover follow 
the hemorrhage, and the former often precedes it. The more copious the 
hemorrhage, the less is the probability that it results from structural lesion 
of the lungs. Our reliance, however, must be on the physical signs of 
incipient phthisis j if absent, we may give an encouraging diagnosis. 

XV. Chlorosis. — In that condition of the young female system which 
is called chlorotic, the lungs and heart often suffer functional derangements. 
The irritable state of the latter gives a frequent jerking pulse, while the 
former is affected in a manner that leads to a great deal of spasmodic 
cough, and sometimes to fits of dyspnoea. The patient loses flesh, and 
becomes pallid from a reduction in the red corpuscles of the blood. The 
perpetual sympathetic or secondary irritation of the lungs, in some cases, 
provokes the bronchial membrane to increased secretion, and expectoration 
is added to the symptoms which excite alarm. Finally, the age at which 
this morbid condition is most frequently developed is that in which tuber- 
culation oftenest begins. In attempting the diagnosis of such a case, it is 
much to know that all these and other pulmonary symptoms pass away in 
numerous cases, on the restoration of a healthy condition of the blood and 
of the uterine function. But when we examine the thorax, we find that a 
deep inspiration may be made without embarrassment, and that the sub- 
clavicular regions emit a healthy sound under percussion ; that in auscul- 
tation they give no bronchial sound, though the vesicular murmur may be 
loud or puerile, but not more audible there than in other regions of the 
chest. It must be admitted, however, that if there be a predisposition to 
phthisis, the chlorotic diathesis may perhaps advance it, and that, after 
existing for a time, the physical signs of tuberculation may be developed. 

XYI. Intermittent Fever. — The last pathological condition which I 



INTERIOR VALLEY OF NORTH AMERICA. 929 

shall mention, in connection with the early stage of phthisis, is relapsing 
intermittent fever. This form of fever is well known as the cause of 
chronic diseases of the liver and spleen, both of which disturb the functions 
of the lungs. Those organs moreover are often left irritable by the fever 
in autumn, and throughout the ensuing winter and spring are liable to 
catarrh. Thus a cough with some expectoration may be kept up, and the 
fever frequently relapsing, with each paroxysm ushered in by a chill, and 
followed by more or less perspiration, the case may sometimes put on the 
aspect of phthisis advanced to the hectical stage. The history of the case 
will aid us in this diagnosis, and those who hold that malarial fever (so 
called) is preventive of phthisis, will be satisfied of the absence of the latter 
when they recognize the presence of the former ; having, however, unques- 
tionably seen a coalition of both forms in the same patient, I would look 
for other means of differential diagnosis in the cases we are considering. 
These may generally be found in the manifest lesion of some of the abdo- 
minal organs, and in the absence of the physical signs of phthisis, with the 
presence in many cases of the signs of pulmonary catarrh. 

I have dwelt long on the differential diagnosis of incipient phthisis, but 
not unprofitably, if what I have said should direct the attention of the 
reader more forcibly to the subject that it may have been before. Having 
written, currente calamo, I cannot suppose either that all has been stated 
that might be, or that all advanced is absolutely correct. The value of an 
exact acquaintance with this subject is twofold : first, it prevents our ne- 
glecting the treatment appropriate to the different maladies which simulate 
the early stage of phthisis ; second, it enables us to resort in due time to 
such means as seem most likely to arrest the progress of tuberculation. We 
must now proceed to a brief inquiry into its pathology and treatment, before 
the stage of suppuration. 



SECTION II. 

PATHOLOGY AND PROGRESS OE PHTHISIS. 

I. Stage of Non-Inflammatory Deposition. — Neither tuberculation 
nor inflammation alone constitutes developed phthisis, but their combination. 
These pathological conditions may reciprocally produce each other. Tuber- 
culation may begin, and continue increasing for a while, before inflamma- 
tion is developed ; and conversely, inflammation may be the primary, tuber- 
culation the secondary, lesion. A tuberculous diathesis, inherited or induced, 
is necessary to the tuberculation of the lung, or any other organ. Under 
its existence, the constituents of tubercle are combined and deposited in the 
vesicular, and sometimes the areolar, tissues of the organ. When the con- 
stitutional lesion is great, this deposit may occur without the action of any 

vol. ii. 59 



930 THE PRINCIPAL DISEASES OF THE 

cause deranging the secretory function of an organ. Thus, during foetal 
life, tubercles are sometimes deposited in the tissues, while they are grow- 
ing, the parts immediately around and in contact with them being perfectly 
natural in appearance; this I have seen myself in different organs. After 
the organs have attained their full development, the same thing may happen ; 
for we often see tubercles in the midst of tissues which show no other ana- 
tomical lesion. Tubercle cannot rigidly be said to indicate a lesion of secre- 
tory action, but rather a lesion of the constitution. The product of secre- 
tion is modified by this latter lesion. The secreting organ does not- load 
itself with a heterologous deposit, in virtue of a morbid condition limited to 
itself, but in consequence of the general diathesis. The material on which 
it acts is no longer normal, and consequently the product of its action is 
more or less abnormal. I cannot pretend to understand the nature of this 
constitutional lesion ; but believe it connected with the great functions of 
assimilation and nutrition, which are modified in a peculiar manner. The 
blood and solids are evidently both affected. Their normal elements may 
be present, but there is imperfection in the vital chemistry, and the lesion 
is spontaneously ingravescent. The tissues do not acquire adequate lateral 
development, or soon lose it, and the fat-producing function is greatly im- 
paired, or even annihilated. Emaciation, indicative of diminished nutrition, 
is indeed one of the most conclusive signs of advancing phthisis, while 
increase of flesh and fat as unerringly indicates an abatement of the tuber- 
cular diathesis. Along with this lesion of nutrition there is an inseparable 
enfeeblement of the vital forces — a defect in the stamina of the constitution. 
These expressions drawn from the vocabulary of the people, may be rejected 
as vague generalization by those who look incessantly and chiefly at local 
derangements of anatomical structure ; but if we fix our minds upon the 
antecedents of such derangements in the malady we are now studying, we 
must, I think, in the present state of pathological knowledge, continue to 
employ them. Various agencies may increase tuberculation of an organ. 
They may act by augmenting the constitutional lesion, or by disturbing the 
function of an organ, as the lungs or the lymphatic ganglia. Thus, spare 
and innutritious diet, or living in a cold, damp and impure air, or a long-con- 
tinued mercurial irritation may increase the former, while inhaliDg an atmo- 
sphere mechanically irritating, or being subjected to sudden changes of 
weather, may effect the latter. I have seen scrofulous or lymphatic tuber- 
culation suddenly follow on mere exposure to protracted cold. It would 
seem that, as the energies of an organ become impaired, its power of bring- 
ing the elements it is destined to combine into a healthy or analogous com- 
pound, is diminished, and the products of its action become more heterolo- 
gous. According to these views, pulmonary tuberculation may be effected 
without inflammation or an inflammatory diathesis; but this condition does 
not constitute phthisis; and it may occur to a certain unascertained extent, 
without being followed by that malady. Opportunities for examining the 



INTERIOR VALLEY OF NORTH AMERICA. 931 

lungs of persons in this stage of the disease do not, of course, very often 
occur. 

We do not well understand why the lungs are so much oftener the seat of 
tubercular deposits, than any other organ. Those of the foetus in utero do not 
escape; but pulmonary tuberculation, both before and sometime after birth, 
is less frequent, compared with that of other organs, than in adult life ; and 
the older the individual grows, the more exclusively is the deposit confined 
to the lungs. The same is true of the pseudo-melanotic deposits in those 
organs which have been shown by Pearson and others to be largely carbona- 
ceous. But why is the deposition of this matter chiefly made in the lungs ? 
Because, as I suppose, they are the great organ for eliminating carbon from 
the blood. If we assume that they are also charged with eliminating ani- 
mal matters, which being retained, contribute to the development of a tuber- 
cular degeneracy of the vital fluid, we may, perhaps, see a corresponding 
reason why they beeome the special seats of tubercular deposition ; and 
why, before they have commenced their special function, they are not more 
frequently affected with tuberculosis than other parts. In support of this 
view, we may refer to, what has been said on the causes of a tubercular 
diathesis, many of which seem to act by impairing directly or indirectly the 
excretory function of the lungs. It certainly seems plausible that the albu- 
minous elements of the blood may be thus transformed into an isomeric body, 
resembling fibrine, which under the law which determines different excre- 
tions upon different organs, would seek an outlet by the lungs, and from its 
spontaneous coagulability, accumulate in the air vesicles, or, as sometimes 
happens, in the connecting cellular tissue. 

I may also refer to the tubercles which are often seen in organs distant 
from the lungs, which show no traces of inflammatory action ; also to the 
interlaminar deposits of tubercular matter in the cornea, which sometimes 
precede strumous ophthalmia ; and to the deposits in the organs of animals 
which have been kept, experimentally, on low diet, in confined and damp 
places. This deposit of tubercular matter in the lungs, is the first local 
effect and evidence of a tubercular diathesis tending to the production of 
consumption, and constitutes the first organic lesion in phthisis, the condition 
on which the incipient pulmonary symptoms depend; and when the amount 
of deposit is sufficient, the first modification of the physical signs. If no 
inflammation should arise, there will be no phthisis. If the deposit is not 
copious, and the tubercular diathesis should, in any mode, be corrected, the 
tubercular matter is decomposed and partially absorbed, leaving behind the 
chalky or pseudo-bony matter, which is sometimes expectorated, at other 
times found in cysts of condensed areolar tissue. Phthisis, in such cases, 
may be said to have aborted. 

II. Inflammatory Stage. — We must now turn to inflammation. When 
it occurs in the lungs of one who has no tubercular predisposition, the lesions 
which ensue are those we have reviewed in the preceding chapters on the 



932 THE PRINCIPAL DISEASES OF THE 

simple pulmonary phlegmasia^ but when it happens in a person predisposed 
to phthisis, but in whose lungs no deposit has yet been made, they almost 
immediately commence. The coDgestion and increased secretion favor the 
deposition of tubercle as well as lymph, if, indeed, the former be anything 
else than the albuminous elements of the blood in a state of unhealthy 
transformation. Thus the materials, both analogous and heterologous, are 
thrown out at the same time and place. The former constitute tissues, 
resembling those of the organ, — the latter, concretions, foreign in character 
to its structure, which reactively keep up the inflammation. This is pri- 
mary tubercular pneumonitis. In this case, the first link of the morbid 
change is the tubercular diathesis, the second, inflammation, the third, the 
secretion of tubercle into the cavities of the organ. The inflammation may 
depend on some ordinary cause, as a change of weather ; which, in a system 
perfectly sound, would afford only the products of ordinary pneumonitis, but 
occurring under that inscrutable lesion of the solids and fluids which con- 
stitutes a tubercular predisposition, its phenomena and effects are modified, 
and its duration rendered indefinite. It is in this sense, that it maybe called 
a specific inflammation. 

Having applied the epithet primary to the inflammation which precedes 
but promotes tuberculation, I may use the term secondary for that which 
follows on the tuberculation, which has been recognized as occurring inde- 
pendently of inflammation. In this case, the diathesis is the first link of the 
chain, the tubercular deposits the second, the inflammation the third. The 
deposits are here the cause of the inflammation, as in the other case they 
were its effects. Yet every inflammation arising in a tuberculated lung, 
does not depend merely on the irritating impress of tubercular matter, for 
such a lung is even more sensible to external influences than a sound organ, 
and hence the inflammation often shows itself in connection with such in- 
fluences, as vicissitudes of temperature and the inhalation of mechanical 
impurities. But whether the cause be entirely internal or partly external, 
it is inflammation set up not only in a tuberculous constitution, but a tuber- 
culated organ ; and henceforth, the pathological state of the lung is the 
same, whether the inflammation have preceded or followed the tubercula- 
tion. This is the inflammatory stage of phthisis, without which that malady 
can have no existence. The lung might be indurated with tubercular matter, 
till death would occur from organic lesion ; but neither the phenomena 
before, nor the lesions after death, which characterize phthisis, would have 
any existence, if inflammation should not be awakened. 

With the rise of this inflammation, there is the rise or increase of fever. 
A tubercular, phlogistic diathesis is established ; and a buffy coat indicates 
hyperinosis of the blood. The intensity of this inflammatory state is very 
different in different cases. In some, the lesion of the constitution is so 
great, that both the fever and the inflammation are of a low grade, and in 
none do they reach the violence of acute simple pneumonitis. This is not 



INTERIOR VALLEY OP NORTH AMERICA. 933 

a hectic, but a phlegrnasial fever ; yet I have seen indications of the rernit- 
tence and of the morning perspirations, which so eminently characterize the 
former. The pulse, in general, undergoes duplication in its frequency, is 
always quick in the stroke, and elastic under pressure, but rarely tense or 
hard, as in the simple phlegmasiae. In this stage of the disease, the thoracic 
symptoms indicate increased violence of inflammation, and the physical signs 
disclose augmented lesion of structure. The inflammation very commonly 
extends to the pleura and generates pain ; which, however, is not as much 
augmented by coughing, or a deep inspiration, as in ordinary pleurisy seated 
lower down, because there is less range of motion in the upper ribs, and the 
pleura of the lung is more affected than that of the thoracic walls. The 
crepitant rale is seldom heard, by reason of the louder bronchial sounds, but 
the latter are modified by the mucous rattle, which the inflammatory involve- 
ment now sets up. Finally, the dulness under percussion becomes greater, 
and its area more extended, in proportion to the increased secretion of coagu- 
lating lymph and tubercle, and the hepatization of portions of sound lung. 

The duration of this stage is indefinite, and not, I think, according to any 
known law. It is certainly not short in proportion as the inflammatory 
symptoms are intense, provided they be not moderated by treatment ; for 
some of the most rapid cases of phthisis do not manifest inflammatory vio- 
lence. The tubercular diathesis is perhaps highly developed in such cases, 
and the infiltration of the lung correspondingly rapid and extensive. The 
termination of tubercular inflammation is invariably in suppuration. The 
previously deposited tubercle softens. By some pathologists the softening 
is regarded as a solution, by the fluids secreted around, by others, as a vital 
process of degradation commencing within it. We need not, however, resort 
to this hypothesis, if we recollect how many membranes and vessels are 
necessarily enclosed in a tubercular mass. They are quite sufficient to 
account for the internal softening, if we suppose them brought into the 
same kind of morbid action with the unenclosed parts. Nevertheless, I see 
no objection to admitting, that many tubercles may have a low and imper- 
fect vital organization • for they are doubtless composed of altered and 
degraded fibrine, which may depart from its normal condition in slighter or 
greater degrees ; and, therefore, some may possess imperfect vital proper- 
ties, while others are altogether destitute of them. Abscesses filled with 
tuberculous pus are now formed, and at length discharging their contents 
into the bronchial tubes, a more copious expectoration ensues ; and the sup- 
purating stage is established. 

III. Hectical Stage. — Tubercular suppuration being established, the 
fever undergoes a modification, and becomes more intermittent. Its type- 
is quotidian, and sometimes doubly quotidian, that is, there is a morning 
and an evening paroxysm, preceded by chilliness and followed by perspira- 
tion. In the apyrexia the heat ceases, but the pulse seldom falls in fre- 
quency to the normal standard. We are apt to think of this fever in con- 



934 THE PRINCIPAL DISEASES OF THE 

nection with the tubercular diathesis, which no doubt modifies it; but still 
it is essentially the fever of suppuration, with which surgery is so familiar, 
when no tuberculation is present. It is doubtless in all cases connected 
with the absorption of pus, and may be more intense in consumption than 
in ordinary suppurations, because the pus in that disease is more heterolo- 
gous than in simple inflammation. In their violence the paroxysms of this 
fever are often unequal, and one or more days may pass with very slight 
attacks, thus strengthening the patient in his characteristic hope of reco- 
very. His pulse, however, continues abnormally frequent, though it may 
fall from 120 or 130 down to 100, or even lower. The contraction of the 
heart is sudden, but not powerful ; and the pulse, although bounding and 
elastic, is never tense, except during acute extensions of the inflammation 
to the pleura. In the purulent stage of chronic bronchitis, with which the 
suppurative stage of phthisis is more likely to be confounded than with any 
other malady, the pulse rarely acquires the frequency which belongs to the 
latter, nor are the chills and sweats in general as great. The distinctive 
diagnosis of the two diseases may therefore to some extent be made out, by 
studying the fevers which respectively accompany them. 

The anatomical lesions of phthisis, the ascertainment of which consti- 
tutes one of the greatest triumphs of modern pathology, are so well known 
— enter so largely into every systematic work, and are made so elementary in 
our schools, that I shall but refer to them, as illustrating its diagnosis, pro- 
gress, and mode of fatal termination. Tubercular suppuration of the lungs 
is attended with constantly-increasing excavation. <?t cannot be doubted 
that the contact of tubercular matter with the tissues into which it is de- 
posited, tends to their destruction. They are, in fact, expectorated along 
with the softened tubercular matter in the pus, which is secreted by the 
inflammation which that heterologous deposit had caused in parts previ- 
ously injured in their vital properties and texture, by its lodgment in them. 
In this way considerable branches of the pulmonary artery are eroded, till 
they pour out large quantities of blood, the fibrine of that fluid having be- 
come so degraded that the arterial tubes could not be plugged up with it. 
The continued extension of the pulmonary cavities depends greatly on the 
tuberculation. The inflammation causes new deposits in the tissue around 
the parts in which the first was made, and these new infiltrations in turn 
react like the first in keeping up the inflammation, destroying the tissues, 
and extending the excavations. But the proportion of degraded to unde- 
graded fibrine — of tubercle to coagulating lymph, is not always the same ; 
and therefore it is not uncommon to find portions of lung which do not 
suppurate into cavities, but simply undergo tubercular hepatization. Con- 
tinued excavation implies great constitutional lesion. When the tubercular 
diathesis is but little developed, the deposits are proportionately small, and 
the inflammation they raise leads to a deposit of lymph having such vitality 
as to form analogous tissues. Excavation does not then take place. The 



INTERIOR VALLEY OF NORTH AMERICA. 935 

heterologous material is expectorated, lymph takes its place, the cavity is 
obliterated by the expansion of the lungs, union of the sides occurs, gra- 
dual contraction and absorption follow, and the surface of the lung over the 
little cavity displays a foveolous and puckered aspect. In other cases, a 
quantity of carbonate and phosphate of lime with animal matter, giving it 
the appearance ,of putty, remains, and is surrounded by a capsule of con- 
densed areolar tissue — false membrane. In other cases still, but I have 
not met with such, the sides of a larger cavity do not coalesce, but it re- 
mains a permanent open sac, lined by or composed of fibro-cartilaginous 
membrane, with a pseudo-mucous surface. In these different cases of ter- 
mination in health, the antecedent of recovery is the correction of the con- 
stitutional diathesis. 

The name of Laennec will for ever stand in connection with the means of 
verifying the lesions which have been enumerated in this and the preceding 
section. When a cavity is filled with unexpectorated matter, if it be near 
the anterior or posterior surface of the lung, the parts above emit a duller 
sound under percussion, the respiratory murmur is absent, and no vocal 
resonance is heard ; but when empty, or but partially filled, its existence is 
made known by a cavernous or gurgling respiration, — by a hollow sound, 
if percussion be made during a deep inspiration, and by pectoriloquy, when 
the patient speaks. As the cavity enlarges, the area of these phenomena 
extends; and when the excavations are multiplied, without communicating 
with each other, the absence of the phenomena over their partition walls 
discloses the fact wiUa a certainty only surpassed by that which depends on 
the knife of the anatomist. 

I wish I could speak in terms of equal admiration of the utility of these 
discoveries in diagnosis. Those by which we are apprised of tuberculation 
of the lung in its early stages, are undoubtedly of great and precious value, 
for they admonish us to lose no time in resorting to whatever hygienic and 
curative measures experience may have pointed out; but the discovery of 
fatal ravages of structure, a few months or weeks earlier than they would 
be disclosed by post-mortem inspection, cannot fairly be placed as high on 
the scale of utility as of mere diagnostic achievement. As still further 
detracting from their practical value in the very emergency in which they 
are most needed, they are perplexingly simulated and rendered uncertain. 
Thus in chronic, non-tubercular bronchitis, there may be such dilatation of 
a bronchial tube as to give respiratory and vocal sounds, which even the 
most disciplined ear may confound with those emitted by tubercular cavi- 
ties. The rule, that by changing the position of the stethoscope we shall 
discover a cylindrical cavity in the latter case, and one more or less circular 
in the former, is not infallible, for the tubercular excavations are often more 
or less elongated ; yet we should by no means neglect this method. We 
must, moreover, place some reliance on the extent of mucous or sibilant 
rattle, generally, or always greater in bronchitis than in tubercular con- 



936 THE PRINCIPAL DISEASES OE THE 

sumption. But passing from physical signs to symptoms, we should seek 
in the history of the patient and his disease, and above all in the degree of 
his emaciation, always greater in phthisis than bronchitis, in the severer 
laryngeal affections, and the stronger tendency to diarrhoea, for the distin- 
guishing symptoms of the two maladies. 

Whatever may be the difficulty, in its early stage, of distinguishing true 
phthisis from other diseases of the lungs, there is none in the latter part of 
the stage we are now studying, for no malady is more distinctly charac- 
terized. The function of nutrition seems nearly or quite suspended, and 
the atrophy increases daily. In some cases, the ends of the fingers consti- 
tute an exception, and are enlarged. This has been regarded as an evidence 
of tubercular disease ; but it is not always present, and I have seen it in one 
case of pleurisy terminating in empyema without tuberculation. The left 
ventricle of the heart is sometimes moderately hypertrophied, the result, 
perhaps, of its unabated frequency of contraction j the mesenteric and bron- 
chial ganglia are frequently increased in size, but the cause is inflammation 
with tubercular deposition. The respiratory and alimentary mucous mem- 
branes become the seats of the same pathological conditions, and the latter, 
especially, invades most of the organs and tissues of the body. Louis and 
others have carefully traced out the progressive tuberculation of different 
parts and the consequent rise of new symptoms, and have thus given greater 
precision to the anatomy and semeiology of this malady; but, in doing so, 
have added nothing to its therapeutics. The most impressive fact in the 
pathology of this stage is the tendency to excretion bv the lungs, the skin, 
the bowels, and the capillaries of the areolar tissue. This tendency seems 
to indicate such an altered and morbid condition of the blood as leads to an 
effort of the sanguiferous system to rid itself of a heterologous element. 
Some one or more of the excretions which have been named are constantly 
in excess. Copious expectoration and profuse morning perspirations very 
commonly co-exist, and when either is much diminished, or the latter does 
not recur, diarrhoea ensues ; finally, the infiltration of serum into the areolar 
tissue of the extremities, produces that oedema which, in every case, precedes 
and presages dissolution. 

The buoyant hope and amiable sentiments, which even this desolation of 
the body cannot extinguish, are but the continuation of the intellectual and 
moral characteristics of the tubercular or strumous diathesis of childhood, 
so often foreshadowing scrofula or hydrocephalus. Even when the under- 
standing forbids the expectation of recovery, perfect resignation in general 
takes the place of hope, and the tranquillity of the patient becomes as im- 
pressive as the previous cheerfulness. This psychological condition belongs 
to no other disease, and is therefore an important aid when we seek to dis- 
tinguish true phthisis from every other pulmonary affection, especially from 
simple, chronic, suppurating bronchitis. There are, moreover, mixed or 
complex cases, in which these characteristics are overshadowed by a diffe- 



INTERIOR VALLEY OF NORTH AMERICA. 937 

rent pathological element. Thus, in phthisis, preceded by well-developed 
dyspepsia, or accompanied by biliary derangements which leave in the blood 
the elements of bile, there is often a hypochondriacal despondency which 
might mislead us in our diagnosis, but for the instructive lessons of auscul- 
tation and percussion. 



SECTION III. 

TREATMENT OE PHTHISIS. 

I. The views which have been taken of pulmonary consumption sepa- 
rate it from the simple phlegmasia of the lungs, give it a constitutional 
origin, and represent the local affection as secondary. The primary lesion 
of constitution they regard as one of feebleness and degradation, in both the 
solids and fluids, and teach that when inflammation and fever arise there is 
increased action with diminished power. They further instruct us, that 
these inflammatory excitements do not terminate spontaneously ; but are 
kept up by the tubercular diathesis of the constitution, which must, there- 
fore, be corrected before they can be arrested. 

II. Treatment before the rise of Inflammation and Fever. — 
Most of what might be said under this the most important therapeutic 
head, has been anticipated in treating of the causes of a tubercular diathesis, 
and need not here be repeated. I may, however, insist that it is only 
by attention to the atage which precedes phlegmasia?: that we can hope to 
accomplish anything in this malady. Every remote cause must be obviated, 
and when an hereditary predisposition exists, the means of correcting it should 
not, as usually happens, be neglected, till signs of pulmonary tuberculation 
show themselves. All who are prone to consumption should know that 
this is the stage, and almost the only one, in which the disease can be 
arrested; yet it is generally the only one in which the least is attempted, 
partly, I am sorry to say, because we do not urge on the predisposed and 
the exposed, that hygiene, which only can prevent or retard the full deve- 
lopment of the tubercular diathesis. 

Disregarding repetition, in a matter of such deep practical importance, I 
propose here to condense the prophylactic suggestions scattered through the 
chapters on the causes of this malady. 

1. The predisposed should especially avoid from childhood all the causes 
which are known to favor the production of such a diathesis, or promote the 
deposit of tubercular matter in the lungs ; and those who have no heredi- 
tary entailment should break off from any and every course of life which 
keeps down their flesh below the natural standards, or excites cough. 

2. An active, even laborious life, is indispensable, as promoting free 
excretion from the lungs and skin, and giving firm vital cohesion to the 
solids. 



938 THE PRINCIPAL DISEASES OF THE 

3. A cool and dry climate should be sought, and hence the visitings or 
migrations of the predisposed, and those in whom a tubercular diathesis is 
forming should be to a higher rather than a lower latitude. A young 
gentleman of Cincinnati, whose parents, sister, and three brothers, died of 
consumption, was seemingly in the first stages of that disease, when he was 
ordered to spend a winter in Cuba. He returned no better, and being led 
by business into the Allegheny Mountains, determined to make them his 
residence throughout the year. His change of climate was equal to that 
from four degrees of latitude, and so far from proving injurious, immediate 
benefit was experienced, and now, after the lapse of seven years, he seems in 
perfect health, with good vigor of constitution. 

4. The lodging-room should be capacious, well ventilated, and cbol. The 
bed should be hard, and so well furnished with covering as to keep the body 
warm without the aid of fire. 

5. Oq rising in the morning, the skin should be washed with cold salt 
and water, and exposed to the air until a feeling of chilliness begins, when 
reaction should be promoted by frictions and dress. 

6. At all times the clothing should be such as to maintain the heat of the 
surface, and enable the individual to spend much of his time in the open 
air during the coldest weather. Even in the house he should be so clothed 
as to render a high temperature of his room unnecessary. 

7. His diet should be nourishing, and include both animal and vegetable 
aliments. The signal failure in the fat-producing function has suggested 
to many an advantage in the administration of fat meats and other olea- 
ginous matters, and the suggestion has seemed to be strengthened by an 
increase of weight under the long-continued use of cod-liver oil. We must 
recollect, however, that it is not the absence of fat, but the lesion of nutri- 
tion, which leads to the absence which does the mischief. On principle, I 
can see no objection to the use of an oleaginous diet; but experience only 
can decide as to its value. 

8. Every form of chronic disease should by appropriate treatment be removed 
in those who are predisposed to, or in whom the process of tubercular de- 
position has commenced. Whatever morbid condition either irritates or 
enfeebles the general system or the respiratory apparatus, may be regarded 
as increasing the tubercular diathesis or inviting the secretion of tubercular 
matter into the pulmonary tissues. This of course is not the place for point- 
ing out the means of accomplishing these important ends. 

9. But what shall be said of anti-tubercular medicines ? In this stage of 
phthisis but little medication has been employed, yet whatever might in 
any degree oppose the progress of the disease at a more advanced period, 
might be expected, a fortiori, to do it in this. If the bark or other bitters 
and the chalybeate preparations can retard the ingravescent progress of 
tuberculosis in the stage of suppuration, would they not more certainly 
accomplish something in the stage of deposition ? But iodine and its pre- 



INTERIOR VALLEY OF NORTH AMERICA. 939 

parations seem to be the only anti-tubercular agents as yet discovered. 
That they are incapable of arresting phthisis when fully formed there can 
be no doubt; but might they not control the forming stage, or contribute 
to correct the predisposition. In that milder modification of the tubercular 
diathesis which has received the name of scrofulous, they are unquestion- 
ably antidotal; and they certainly deserve a fuller and longer trial in the stage 
we are now studying than they have yet received. In cases accompanied 
with debility and little tendency to fever, especially those of a chlorotic or 
ana3mic character, the hydriodate of iron would be most proper ; but with 
less reduction of the vital forces and greater tendency to fever,, the hydrio- 
date of potash would be preferable. Unfortunately, however, for all expe- 
rimental medication in this early stage of the malady, patients generally 
regard it too lightly either to apply for advice or submit to the regular and 
protracted use' of any remedy. 

III. Treatment of the Phlegmasial Stage. — The rise of inflamma- 
tion and fever is more or less rapid, and according to the constitutions of 
patients the phlogistic excitement is more or less intense. When violent it 
must be met with antiphlogistic treatment, for as the inflammation is one 
of the causes of pulmonary disorganization, it may soon destroy life if it be 
not moderated. It must never be forgotten, however, that tubercular pneu- 
monitis cannot be cured by antiphlogistic treatment, hoicever urgent may be 
the indications for its use. It is but palliative. Both the inflammation 
and the fever may be moderated (but they cannot be subdued), except in 
the case occasionally met with, in which the tubercular degradation is slight, 
and the inflammation has been awaked by external and common causes. I 
have not greater faith in any therapeutic conclusion than this, having seen 
the antiphlogistic method fail in a number of cases indefinitely great, while 
I never saw it succeed in one where the evidences of tuberculosis were well 
marked; and if I am not mistaken, this accords with the present state of 
experience both in this country and Europe. A depleting and debilitating 
treatment, moreover, is not merely ineffectual, but often injurious by favor- 
ing a more rapid progress in the tuberculosis ; and hence there is an addi- 
tional reason for employing it with circumspection and reserve. 

The means which I have generally seen employed, are bloodletting, tartar 
emetic, digitalis, calomel, and blisters; which may be taken as represen- 
tatives of the whole. It may be said of all that they cannot with safety to 
the patient be pushed as far as in simple pulmonary inflammation, wherever 
seated, of the same grade of excitement. Thus, copious and quickly repeated 
bloodlettings, grain doses of tartar emetic, liberal portions of digitalis, and 
calomel in salivating quantities are inadmissible ; and each must be em- 
ployed to a limited extent only, or the patient will be brought into a state 
of exhaustion, from which he may never fully recover. He may be relieved 
from many of the sufferings dependent on the inflammation; but still it 
goes on to suppuration, and the tubercular diathesis is increased. 



940 THE PRINCIPAL DISEASES OF THE 

In its relations to the antiphlogistic method, tubercular pneumonitis has 
some close analogies with many other fevers. The eruptive, the typhous, 
and the autumnal or periodical, in certain cases demand that method, though 
its effects are scarcely ever curative. In the two former classes, important 
organs are preserved from fatal lesion, and the fevers having run their re- 
spective courses, convalescence takes place : in the latter, the same method 
prepares the system for the effective operation of quinine and other periodics. 
The eruptive fevers cannot be arrested, but their general termination is in 
health ; nearly the same remarks are applicable to the typhous ; but the 
fever of pulmonary tuberculation, equally difficult to arrest, generally ter- 
minates in death. Such being the case, it cannot be said that the antiphlo- 
gistic treatment has been often the cause of death, yet it has sometimes 
hastened that event, and still oftener subjected patients to the expense and 
discomforts of officious medication, the end of which was disappointment 
and greater professional discredit than if less had been done and fewer ex- 
pectations excited. 

After this distinct limitation of the powers of the antiphlogistic method, 
it seems unnecessary to dwell on special rules of practice, or to suggest for- 
mulae adapted to particular conditions of the system ; and I shall conclude 
with the following practical remarks. First, it is not proper to subject the 
patient to as rigid abstinence, as when we treat the simple phlegmasias, because 
of the unhealthy state of his nutrition; second, if he should be in the use of a 
preparation of iodine or any other medicine supposed to control tuberculosis, 
it should be continued, notwithstanding the employment of antiphlogistic 
measures ; third, the patient should not, if possible, be kept in bed, but 
permitted and encouraged to take that exercise in the open air, which is 
one of the most efficient anti-tubercular measures; fourth, in almost every 
period of this treatment, should the cough or muscular pains be troublesome, 
some preparation of opium may be combined or alternated with the other 
remedies. 

IV. Treatment of the Suppurating Stage. — 1. Obstacles to cica- 
trization. In the simple phlegmasias suppuration is often followed by re- 
covery, is indeed one of the methods of cure, which, so to speak, are adopted 
by nature. Thus we have all seen pleurisy, pneumonia, and hepatitis ter- 
minate in health through the instrumentality of purulent secretion. The 
same result has been looked for in tubercular inflammation, and the patho- 
logical anatomists have furnished some evidence of its reality. But this can 
never happen except when the tubercular diathesis is slight, or has by appro- 
priate treatment been corrected. When the deposit of tubercular matter is 
extensive before inflammation is established, or the lesion of the constitution 
is so great that the deposition is kept up by the inflammation, suppuration 
cannot lead to recovery, and this is generally the case. For that process to 
prove curative, the inflammation around the abscess must not be purulent 
but adhesive ; the inflammation surrounding the tubercular abscess is, how- 



INTERIOR VALLEY OF NORTH AMERICA. 941 

ever, of the former kind, because, as we have seen, it deposits tubercle as 
well as lymph, and that heterologous substance immediately promotes sup- 
purative action. Thus nature is thwarted in her methodus medendi, and the 
work of pulmonary disorganization goes on to a fatal termination. 

2. Antiphlogistic Treatment. — If the antiphlogistic treatment cannot arrest 
the inflammation which precedes all suppuration, much less can it subdue the 
stage we are now considering. It is, indeed, no longer admissible, except 
now and then, when some exciting cause has quickened the inflammation into 
great activity, or extended it to the pleura, the bronchial tubes, or to portions 
of the vesicular structure not previously affected. Such exacerbations must of 
course be met with antiphlogistic measures ) but we must ever bear in mind 
that they are but protective against new lesions, not curative of those pre- 
viously existing, and may, by their exhausting influence, accelerate the death 
of the patient. As a general rule, it may be affirmed, that all depletory and 
debilitating measures are not merely ineffective but positively injurious in 
this stage. Thus low diet, venesection, sedative nauseants, such as tartar 
emetic, squill, digitalis, colcbicum, sanguinaria canadensis, and lobelia in- 
flata; a salivation, and unrelenting counter-irritation with blisters, tartar 
ointment and issues, should be prohibited, except under the temporary 
aggravations of the inflammation, which have been mentioned. In purulent 
bronchitis these agents are of unquestionable value, and this has too often 
led to their officious administration in the suppurative stage of tubercular 
inflammation, when an opposite method would have been preferable. To 
that method we must now devote a few paragraphs. 

3. Tonic Treatment. — While the treatment which has been reviewed 
looks to the inflammation in the lungs, the tonic or corroborant method 
looks to the tuberculosis of the general system, a condition which keeps up 
the inflammation. There is undoubtedly a degree of the latter, which, for 
the time being, contra-indicates all agents which increase the excitement; 
but we assume it as a therapeutic law, that in all fevers and inflammations 
of a specific kind such agents are, on the whole, more admissible than in 
corresponding grades of inflammatory orgasms depending on common 
causes. Thus diffusible stimulants have been administered in scarlatina 
with apparent advantage, or, at least, without injury, and opium and sul- 
phate of quinine may be given in our remittent autumnal fever, under 
grades of excitement which would render them inadmissible if it arose from 
an ordinary cause. The usual intensity of hectic fever and suppurative 
tubercular inflammation of the lungs, does not, in fact, exclude the tonic 
treatment, and my own experience carries me with those practical men, who 
have preferred that method to the opposite, under which, if it have been cor- 
rectly asserted, the sufferings of the patient are less, but his strength is 
more rapidly wasted away. I am far from affirming, that the corroborant 
treatment can be made radically curative, but its tendency is in that direc- 
tion ; and under its influence we generally see the strength of the patient 



942 THE PRINCIPAL DISEASES OF THE 

better maintained, and in many cases bis emaciation for a while arrested. Of 
course a great variety of means may be employed under this method ; but 
the following I suppose to be the best : — 

1. A mixed, nutritious, and easily digestible diet; which should never 
exceed half the quantity the individual would take in health. 2. The cinchona 
bark in substance or decoction. 3. The infusion, by displacement, of the 
bark of our wild cherry tree, Primus Virginiana. 4. The compound tincture 
of benzoin. 5. The Mistur a J err i compos itse. 6. The iodide of iron. 7. 
Opium. The last is undoubtedly of much value and comfort to the patient ; 
and I prefer solid opium to its tinctures or salts, as more enduring in its 
effects, and harmonizing better with the tonic treatment. 8. Frictions of 
the skin with coarse towels, dried after being dipped into a saturated solu- 
tion of common salt, may be made on the access and decline of the morning 
perspiration. 9. In winter as often and long as possible, the inhalation 
through an India rubber or some other tube of the cold external air. 10. 
Riding, and other modes of outdoor exercise, to be practised daily, and not 
omitted on account of cold weather, but the skin to be so protected as that 
it shall not feel the low temperature ; to which end it may be necessary to 
resort to furs, as more defensive against cold than woollen garments. But 
these modes of protection should be laid aside in the house, the air of which 
should have free access to the surface of the body. 11. The bedding of the 
patient should be elastic, but as hard as can be borne in his emaciation, and 
the clothing which he has worn next his body through the day should be 
laid aside at night. Both in summer and winter the skin should be pro- 
tected at night from damp or cool air ; and in the latter season so well de- 
fended, that a stream of cold air may be admitted through his inhaler, and 
discharged, by dispersion, through a bag or sack tied over its mouth-piece, a 
little above his face, so that, while it may be breathed, it cannot act on the 
surface of his body. 

It is unnecessary that I should add anything to this brief catalogue of 
tonic means ; for they are unquestionably the best known to us. A great 
variety of balsams and terebinthinates have long been used, and exerting a 
stimulant power may be regarded as auxiliary to the agents which have been 
named ; but in attempting to estimate their exact value, I should be carried 
over ground so often and ably trod, that I prefer to avoid it. 

That the method of constitutional invigoration has frequently arrested 
phthisis after its advancement to the suppurative stage, must. I think, be 
admitted; but, on the other hand, it has too generally failed to allow of its 
being regarded with confidence. When successful, the tubercular diathesis 
has perhaps not been highly developed, or the amount of pulmonary deposit 
great. I am disposed to consider it merely as a basis of treatment — a plan 
to be pursued in the absence of a specific remedy, and which would still be 
proper and necessary, if a medicine entitled to that epithet should ever be 
discovered. 



INTERIOR VALLEY OF NORTH AMERICA. 943 

4. Miscellaneous Remedies — palliative and curative. — As in cancer, hy- 
drophobia, and other incurable diseases, so in phthisis, many things have 
by persons, both in and out of the profession, been bruited abroad as radi- 
cally curative or strikingly palliative. The cases cited in support of their 
claims have probably sometimes been of the mild and limited kind of which 
I have spoken, but much, oftener of non-tubercular, chronic bronchitis. 
Most of the bepraised measures have no doubt palliated the symptoms, and 
afforded comfort to the patient, whereupon it has been supposed, that had 
they been employed earlier, or with greater regularity, 'or had the patient 
not " taken cold " (the common expression for the exacerbations to which 
all consumptives are liable) they would have eradicated the disease. By 
this kind of reasoning a palliative has been raised to the dignity of a radical 
remed} 7 . A milk diet; breathing an atmosphere impregnated with carbonic 
acid, chlorine, oxygen, and other gases ; emetics of the sulphate of zinc or 
copper; the tincture of digitalis; hydrocyanic acid; the inhalation of the 
vapor of boiling tar, and the drinking of tar water; the inhalation of ether 
holding cicuta in solution, and the same use of volatilized iodine in combi- 
nation with that vegetable narcotic, have all had their day; and while the 
whole, in different cases, have mitigated the violence of particular symp- 
toms, none have perhaps done more. It is unnecessary to repeat the in- 
structions for their use contained in all our text and hand-books of practice. 

The present object of hope and trial is Cod-Liver Oil. My own experi- 
ence and observations afford results from this article, which correspond with 
those of the profession at large. It is one of our best palliatives, but, with 
some apparent exceptions, unequal to the cure of consumption. It must be 
admitted, however, that its use has been so generally deferred to an advanced 
stage of the disease, and this will probably ever be the case with most reme- 
dies, as the forming stage of consumption seldom comes under the observa- 
tion of a physician, often indeed proceeds without the notice or conscious- 
ness of the patient. From the great variation in the duration of consump- 
tion, it is, I think, uncertain whether this medicine has the power of pro- 
longing life ; yet the abatement of most of the symptoms, the temporary 
arrest of the emaciation and the partial restoration of the tissues, especially 
the adipose, seem to indicate that life may be prolonged by it. The theory 
started on the discovery of iodine and bromine in cod-liver oil, that the 
benefit of its use in phthisis depends on those agents, seems at present to be 
waning, on the ground, in part, that they exist in quantities too minute to 
produce any effect. This, however, is gratuitous. The average results of 
the analysis of five specimens of cod-liver oil by Herberger,* gave -972 of 
a grain of iodine in 1000 grains of the oil, and -151 of bromine in the 
same. Taking these together, the proportion is 1-122 in the 1000 grains. 
Thus, without going into fractions, it may be affirmed, that every ounce of 
the oil contains nearly half a grain of iodine, and more than that amount of 

* Pereira, vol. ii. p. 805. 



944 THE PRINCIPAL DISEASES OF THE 

the two substances united. Hence, if the oil is given in the quantity of 
only two ounces in the day, at least a grain of these active elements is intro- 
duced into the system, which is quite sufficient, when combined for awhile, 
to produce decided effects. Of this we have conclusive proof in the cure 
of scrofula (dependent on a modification of the tubercular diathesis) by the 
administration of this oil ; for it will scarcely be held, that the whole benefit 
is produced by the oleaginous elements of this organic compound, seeing 
that animal oils have not been found curative of scrofula, while iodine has. 
It is true, however, that iodine has not done the good in phthisis that has 
been done by the oil, of which it is one of the ingredients. But we may 
admit that the oil is a better solvent of iodine than water, and that when 
deposited in the tissues, that active agent still continues with it; while, if 
given in watery solution, it is conveyed out of the system by the excretions. 
To obtain a constitutional alterant effect from any agent, it must not pass 
directly from the stomach to the kidneys, or some other eliminating organ, but 
be carried to the tissues by and with some nutritive substance which can be 
deposited in them. That cod-liver oil is thus deposited, we have evidence 
in the fact that, during its use, the lost fat of the patient is to a certain de- 
gree restored. I would not, however, ascribe the increase of weight under 
its use entirely to the introduction of the oil, for animal fats which do not 
contain iodine, fail in arresting the emaciation of the patient. The oil then 
facilitates the distribution and action of the iodine, which, thus distributed, 
improves the impaired nutritive functions, favors the deposition and deten- 
tion of the oil itself, revives the molecular action on which the elaboration 
of the protein elements of the blood depends, and thus retards the tuber- 
cular degradation. I cannot agree with Acherson and Bennett, that these 
beneficial effects are produced solely by supplying the albumen with oil 
(necessary, as they believe), for the construction of either cells or their 
nuclei, for the question still remains to be answered, why or how has the 
deficiency of fatty matter been produced ? That deficiency implies a previ- 
ous lesion, which, continuing uncorrected, the oil introduced from without, 
can only be a factitious substitute for that which the system has failed to 
elaborate or retain, and the antecedent morbid state of the nutritive function 
remains. For this state, when the local affection is seated in the lymphatic 
ganglia, iodine, in most cases, proves a radical cure ; but when seated in 
the lungs, it as generally fails to work out that desirable end. The reason 
of this failure, when employed before extensive and fatal anatomical lesions 
of those organs have been produced, is as little known as the reason why in 
children born of tuberculous parents, the local affection will be seated in 
the lungs of one, and the cervical or mesenteric ganglia of another ; or why 
scrofula should prevail over phthisis in Germany and Russia, while the 
reverse is true in England and America. 



INTERIOR VALLEY OF NORTH AMERICA. 945 

CHAPTER XX. 

CARDIAC INFLAMMATIONS. 



SECTION I. 

INTRODUCTION. 

The inquiries which I have made lead to the conclusion that inflamma- 
tions of the tissues of the heart are not often recognized by our physicians, 
either during life or after death. This may be attributed to two causes. 
1st. It must be confessed that most of us, from studying so little in hospi- 
tals, are but little skilled in the differential diagnosis of cardiac diseases, 
and generally content ourselves with the discovery that the patient has a 
disease of the heart. 2d. When it proves fatal, the opportunity of inspect- 
ing the organ is not often afforded. But after making due allowance for 
these reasons why cardiac inflammations do not seem to be of frequent 
occurrence among us, I am disposed to believe that in reality they are not 
so common in this country as in the great cities of Europe. I can certainly 
say, that through the last twenty-five years, during which I have known 
more of their diagnosis than before, the number of cases in my own prac- 
tice, or which I have seen in consultation, has been small. In the post- 
mortem examinations at the Louisville Marine Hospital, for the last nine 
years, inflammatory lesions of the lungs, spleen, stomach, bowels, and liver, 
have been so frequent, compared with those of the heart, as to show con- 
clusively that each of them is far oftener inflamed than that organ. Never- 
theless, I cannot doubt that many cardiac inflammations exist undetected 
by us, and are referred to two other heads, to which, indeed, we are prone 
to refer nearly all cardiac affections — these are morbid irritability and 
hypertrophy. The former of these is undeniably a frequent disorder, but 
among the cases which occur in young men, there are no doubt many real 
though undistinguished inflammations. Hypertrophy, so called, is also not 
very rare, but in many cases there was, no doubt, an inflammation not re- 
cognized at the time, to which the structural derangement should be refer- 
red. Both for the interest of society and the credit of our profession, it is 
desirable that we should have a better acquaintance with the diagnosis of 
cardiac diseases, especially inflammations in their early stages. The reluc- 
tance of surviving friends to allow post-mortem inspections, as a means of 
verifying our diagnosis, tends greatly to discourage the study of the latter; 
but we should not forget that a cardiac inflammation, not speedily reduced, 
eventuates in some form of organic lesion, the supervention of which is in 
some degree a substitute for the dissection of those who die, inasmuch as it 
proves that an inflammation had existed, thus illustrating our diagnosis, 

vol. ii. 60 



94.6 THE PRINCIPAL DISEASES OF THE 

and encouraging us to persevere. It will be in vain, however, to aim at 
accuracy in this branch of diagnosis, while, from lack of personal observa- 
tion, we remain ignorant of the normal sounds and impulses of the heart. 
For the want of this physiological knowledge we are without excuse ; and 
the absence of it not only disqualifies us for clinical observation, but even 
for a beneficial study of the elaborate works on maladies of the heart, with 
which the great cities of Europe have latterly supplied us. In what I am 
about to write, there will be no (abortive) attempt to equal the profound 
and minute dissertations to which I have referred, but availing myself of 
them, in connection with my own limited and imperfect experience, I hope 
to present the subject in a way that will render it intelligible and practi- 
cally useful to those for whom this work is designed. 



SECTION II. 

CLASSIFICATION AND GENERAL SYMPTOMS OF CARDIAC INFLAMMATIONS. 

I. Classification. — It is obvious, from the anatomy of the heart, that 
its inflammations may be seated in different tissues, as the organ consists of 
hollow muscles with a fibro-serous membrane on their outside, and a serous 
membrane within, which membranes are disconnected and perform different 
functions. The inflammation of the muscles is carditis; of the fibro-serous 
membrane, pericarditis ; of the serous membrane, endocarditis. In times 
past these inflammations were grouped under one name, carditis, and the 
muscular substance was then supposed to be their chief seat. Pathological 
anatomy has demonstrated the fallacy of this generalization, and shown 
that in fact carditis, per se, is a very rare, if not an imaginary affection ; 
and that the muscular disturbance, in these inflammations, is generated by 
the contact of an inflamed membrane. This is what might have been ex- 
pected, for, first, inflammation of a muscular tissue is exceedingly rare. 
That of the mucous membrane of the stomach and bowels is often arrested 
by the muscular coat beneath, and the skin is often severely inflamed with- 
out involvement of the muscles which it covers. The heart moreover has 
very little interposed cellular tissue, which still further favors its exemption 
from inflammation. Secondly. Of all the tissues of the body the mem- 
branes are most liable to inflammation. When thus affected, they carry 
functional disorder into the organs which they invest, and, to a certain 
extent, the inflammation may spread into the parts beneath. Thus an in- 
flammation of the pleura pulmonum disorders the functions of the lungs 
before it becomes, by extension, a peri-pneumonia ; and arachnitis occasions 
great disturbance of the intellectual functions, while the inflammation has 
not yet dipped into the convolutions of the brain. If inflammation of the 
muscular substance of the heart ever does occur without the investing mem- 
branes being involved, its diagnosis would, I suppose, be impracticable, 



INTERIOR VALLEY OF NORTH AMERICA. 947 

while its proper treatment would be the same which their inflammations 
require, and hence, in reference to its symptoms and treatment, it is un- 
necessary to assign it a distinct head. Even pericarditis and endocarditis 
often coexist, or mutually excite each other, and in their early stages mani- 
fest themselves by symptoms so much the same, that it will simplify their 
study to enumerate such as are common to them and also to carditis. 

II. Early Symptoms of Acute Cardiac Inflammation. — In what- 
ever tissue it may be seated, this inflammation when acute is accompanied 
by fever, in which the patient often complains of a burning and acrid heat 
of the skin. The pulse, always increased in frequency, is in other charac- 
teristics exceedingly variable ; unequal in the number of beats in equal 
times, generally intermittent, sometimes full, at others small and con- 
tracted. In the region of the heart there is pain, either dull and constant, 
or occasional and lancinating. In some cases it extends beyond the cardiac 
region, and attacks the pectoralis and the muscles of the left arm. Now 
and then it invades the diaphragm, and seems to be in the abdominal 
cavity. Invariably there is a sense of anguish in the region of the heart, 
and upward pressure against the diaphragm in the epigastrium or left hypo- 
chondrium increases both this symptom and the pain, while it disturbs the 
heart's action. The same effects follow pressure over the intercostal 
muscles. A sense of tightness or constriction occurs across the prsecordial 
region. Dyspnoea and a dry, hacking cough are never absent, and both are 
increased by every kind of effort, even change of posture. Under attempted 
exercise, the tendency to fainting is very great, while the pulse becomes 
much accelerated. When the precordial region is examined by the ear, 
the sounds of the heart are found to be loud, and its movements sudden, 
convulsive, irregular, and with strong impulse. The brain never fails to 
sympathize. The spirits of the patient are always depressed, and delirium 
often supervenes. These symptoms being present, we can scarcely doubt 
the existence of cardiac inflammation ; but still, before declaring the diag- 
nosis of the case, it is necessary to ascertain that the inflammation is not 
seated in the precordial pleura, or in the portion of lung which occupies 
that region. This being settled, in the mode hereafter to be pointed out, 
the case may be pronounced cardiac inflammation, but its special seat will 
remain to be determined. 

III. Early Symptoms of Subacute Cardiac Inflammation. — When 
an inflammation of any of the tissues of the heart comes on slowly and 
insidiously, its detection is often difficult; and it is sometimes supposed to 
exist when it does not. For a long time it may be that the lesion of func- 
tion in the heart is unproductive of any decided injury of structure, with- 
out which the physical signs, ultimately so intelligible, are obscure or am- 
biguous ; still it is of great moment to ascertain its existence in time to 
avert the organic lesions on which those signs depend. It is no part of our 
duty to wait for the ravages of a morbid action, as a method of ascertaining its 



948 THE PRINCIPAL DISEASES OF THE 

existence; for the very object of the knowledge is the prevention of structural 
derangement. If our patient have a quiet heart, and an equable not over 
frequent pulse, we may pronounce that cardiac inflammation does not exist; 
but on the other hand, if his heart beat convulsively and frequently, inflam- 
mation may or may not be present. Now, there are conditions of the 
system which produce this kind of pulse when no cardiac inflammation 
co-exists; and it is the function of the physician to distinguish between 
them. But still further, some of these conditions, as we shall see in a sub- 
sequent section, are themselves causes of cardiac inflammation, and hence 
palpitations which were at first altogether " nervous" and sympathetic, come 
at length to be inflammatory; thus, still farther increasing the perplexity 
of the case. 

The diatheses or morbid conditions which generate palpitations, simula- 
ting those from subacute cardiac inflammation, as I have observed them in 
this country, are chiefly the following : a. The Dyspeptic; b. The Icteric ; 
c. The Hysteric ; d. The Chlorotic ; e. The Utero-Hemorrhagicj or Menor- 
rhagic ; f. The Plethoric ; which we must consider seriatim. 

a. The Dyspeptic. — It is well known that dyspepsia is a wide-spread- 
ing and prevalent endemic of this country, and that it affects young men 
more than any other class of persons, they being at the same time most 
liable to cardiac inflammation. Now, dyspepsia produces palpitation of the 
heart, and gloominess of mind, both of which are present in the early not 
less than the latter stages of cardiac inflammation. Still further, many cases 
of dyspepsia are inflammatory, and, of course, accompanied by more or less 
feverishness after a full meal, or in tne evening. A case of this kind pre- 
sents broad ground for doubt and hesitation as to the condition of the heart, 
while that of the stomach can scarcely be misunderstood. If, upon exami- 
nation, the precordial region should be found tender, or the seat of pain, the 
conclusion ought to be, that incipient carditis is superadded to more advanced 
gastric inflammation, for there is a high probability that such is the case; 
and if it should be otherwise, the treatment which the dyspepsia demands 
will not be injurious. If the dyspepsia, upon a careful inquiry into the 
signs of a phlogistic diathesis, should be found not to be inflammatory, of 
course the cardiac affection ought to be regarded as consisting simply in 
morbid irritability. Palpitations depending on this cause, it has been said, 
are not increased by exercise, while those which accompany cardiac inflam- 
mation are ; I feel assured, however, that muscular effort does, in many 
cases, increase them ; though it will not excite the pain or anguish in the 
region of the heart, and the tendency to fainting, which it is wont to occa- 
sion when inflammation is present. Still, palpitations arising solely from 
an irritable state of the heart may lessen during protracted exercise, while 
those depending on inflammation will not. The former abate when the 
patient is quiet in bed, but the latter are often augmented under such cir- 
cumstances. Finally, when the patient lies on his left side, he will feel 






INTERIOR VALLEY OP NORTH AMERICA. 949 

pain, oppression, or uneasiness, if the heart be inflamed ; but only a discon- 
tent with the position, from hearing the sound and feeling the movements 
of heart, if it is not. 

b. Icteric. — I use this term as a convenient expression of that state of 
the system which is present when there is a defective secretion or excretion 
of bile, and consequently its elements are left in the blood, to irritate and 
depress the nervous system. Palpitations of the heart are often present in 
such cases, and suggest in the patient an apprehension of " disease of the 
heart." Should the biliary derangement arise from hepatitis, occasioning 
fever, there would be some ground for suspecting cardiac inflammation ; 
which, however, is very seldom consequent on hepatic inflammation. This 
fact, taken in connection with the criteria presented in the last paragraph, 
will generally conduct us to a correct decision. 

c. The Hysteric. — Individuals of both sexes, who have a lymphatic tem- 
perament, are liable to palpitations of the heart, which are induced by 
slighter exciting causes in women than men. Their decidedly paroxysmal 
character, together with the presence of other hysterical symptoms, and the 
immediate antecedent action of some exciting cause, moral or physical, will 
generally enable us to declare that they do not depend on inflammation. 
If, however, a person of the temperament we are now considering should 
labor under habitual constipation with alvine accumulations, or from great 
depletion of any kind have fallen into a state of general debility, or is sub- 
jected to the protracted influence of some depressing emotion, or is given 
up to secret and impure indulgences, the palpitations may become so con- 
stant and convulsive as to suggest the possibility of cardiac inflammation. 
Under such circumstances, we must depend on a searching scrutiny into the 
causes, external and pathological, which may be acting on the patient, and 
consider them in connection with the symptoms of cardiac inflammation 
already mentioned, when we shall generally be brought to a correct decision. 
In this case the appearance of the drawn blood may aid in the diagnosis. If 
there be no cardiac inflammation it will be free from buff. 

d. Chlorotic. — This diathesis is very often attended with palpitations, 
which are prone to be habitual, though subject to exacerbation. When the 
stethoscope or ear is applied to the precordial region, a bellows, or some 
kind of murmur, one of the signs, as we shall presently see, of endocarditis, 
is often heard. When blood is drawn it is generally buffed. The subjects 
of it, moreover, are of the age most liable to cardiac inflammation. At 
first view, therefore, these cases would seem to present much diagnostic diffi- 
culty ; but we are not without the means of removing it. 1. Young men 
are most subject to cardiac inflammation — young women to chlorosis. 
2. The signs of chlorosis are generally well developed. 3. The abnormal 
sounds of the heart are variable, and may cease and be renewed in chlorosis, 
while they are constant in endocarditis. 4. In the latter, the blood is but 
little reduced in its red corpuscles, the buff depending on excess of fibrine ; 



950 THE PRINCIPAL DISEASES OF THE 

while in the former they are greatly diminished, and although there may 
he a buffy coat, there is no increase of fibrine. 5. In chlorosis there is 
seldom any febrile heat — in cardiac inflammation some degree of fever is 
generally present in the evening, however mild may be the attack. 

These facts will generally be sufficient to guide us to a correct conclusion. 

e. Utero-hemorrliagic. — By this (pro tempore) phrase, I mean to express 
that condition of the female system which is present to a greater or less 
degree throughout the era (often protracted) of the final cessation of the 
catamenia. As every physician knows, nervous irritations are more or less 
developed, even when the menorrhagia is moderate, and become violent and 
protracted when it is profuse. Through the whole period, fits of palpitation 
frequently occur, connected with gloom and apprehension, as deep as what 
attend on maladies of the heart. These symptoms should not suggest to us 
the existence of cardiac inflammation so much as some organic affection, for 
neither the sex nor age of the patient favors the existence of the former so 
much as the latter. Our means of differential diagnosis are, 1st. An in- 
quiry into the condition of the heart before the menstrual irregularity 
began. If no signs of cardiac disease then existed, the probabilities are 
against the suggestion of its existence afterwards. 2d. A resort to auscul- 
tation and percussion, when, although we may hear murmurs, we shall not 
perceive the signs of hypertrophy or dilatation. 3d. The administration of 
a liberal narcotico-antispasmodic, which, if there be only morbid irritability, 
will, for the time being, effectually quiet the palpitations, an effect that 
would not follow if organic derangement existed. 

/. The Plethoric. — This condition, the opposite of the two last, may gene- 
rate palpitations. They occur oftenest in young and middle-aged persons of 
a sanguineo-lymphatic temperament. There is a sense of fulness, a heaving 
and convulsive struggling in the region of the heart, with irregularity rather 
than frequency of contraction, unaccompanied by pain and soreness. When 
these signs are taken in connection with the general indications of plethora, 
we may, with much confidence, decide against the existence of inflammation; 
but if the drawn blood be examined and found normal in the quantity of 
fibrine while its red corpuscles are increased, we may feel assured that our 
diagnosis is correct. 

If I have dwelt on these subjects, it is because the attention of the people 
has, in latter times, been strongly directed upon maladies of the heart, and 
physicians are almost every day called upon to make decisions in diagnosis. 
When they meet with cases of full-grown organic disease, the decision is 
easily made ; but in the early stages, when, as I believe, more or less in- 
flammation generally exists, the task is often difficult. To decide that 
inflammation is present when it is not is to bring distress of mind upon the 
patient and discredit on the physician ; while, on the other hand, to mistake 
it for mere morbid irritability, is to allow the malady to pass uncombated 
to an incurable stage. 



INTERIOR VALLEY OF NORTH AMERICA. 951 

SECTION III. 

PECULIAR SYMPTOMS AND PATHOLOGICAL CHARACTER OF PERICARDITIS. 

When the inflammation is seated in the pericardium, that membrane, the 
cellular substance beneath it, and, doubtless, the exterior part of the mus- 
cular substance, are gorged with blood; in other words, they are swollen, 
and when percussion is made, the area of dulness is found to be more exten- 
sive than in health, provided the patient be erect or inclined a little forward 
when the observation is made. But another pathological condition contri- 
butes at an early period to the same phenomena. As in all other cases, the 
inflammation is no sooner set up than a secretion of serum and coagulating 
lymph into the cavity of the pericardium commences, and by distending that 
sac, augments the region of dull sound. If this effusion should be copious, 
it diminishes both the impulse and sounds of the heart, and might lead us 
falsely to suppose that the inflammation had abated. On this effusion 
depends a physical symptom, now universally regarded as pathognomonic. 
In health the heart, in its systole and diastole, moves within the pericar- 
dium, which is attached below to the diaphragm, and above to the cardiac 
extremities of the great vessels, without friction; but when the internal 
surface of that membrane has become roughened with lymph, or flocculi of 
fibrine are rolled between the cardiac and pericardiac serous surfaces, a fric- 
tion sound is generated. Such a sound might result from blood extrava- 
sated into that cavity; but in the case of hemorrhage (other than that which 
occasionally occurs, to a small degree, from parts which are intensely 
inflamed) the rational signs of inflammation which have been enumerated 
will be absent. Being present, the rubbing or friction sound becomes 
demonstrative of pericarditis. This sound has received a variety of names 
from different writers, but compared by most of them to tne creaking of 
new leather, to rasping, grating, or the rubbing together of two pieces of 
parchment. For all practical purposes it is quite sufficient to indicate it as 
a sound emitted by the motion of two roughened surfaces on each other. 
But this sound is not heard in every stage of the disease, for the surfaces 
must be near each other to produce it. Thus, at the beginning of the effu- 
sion, it may be present in a moderate degree, then cease, because the 
quantity of liquor sanguinis has become such .as to part asunder the sur- 
faces which throw it out, and then return when the serum has been absorbed 
and the membranes are shaggy from adherent lymph. There are but two 
sounds emitted by the thorax with which this can be confounded : 1st. That 
occurring in pleurisy from a similar pathological cause. To discriminate 
them from each other, it is only necessary to direct the patient to hold his 
breath, when the latter will of course cease. 2d. That given out by the 
valves of the heart when in the condition to be presently described. This, 
however, is loudest near the base of the heart, seems deep-seated, and is 
single, while that produced in the pericardium is heard equally over the 



952 THE PRINCIPAL DISEASES OP THE 

precordial region, seems superficial, and is double, — that is, emitted both 
by the systole and diastole of the heart, though louder in the former than 
the latter. 

The progress and effects of pericarditis deserve serious consideration. It 
may prove fatal in a few days. The copious effusion into the pericardial 
cavity greatly embarrasses the action of the heart, which is deeply disturbed 
in its irritability and performs its function imperfectly ; the due return of 
blood from the brain is thus retarded, and that organ still further injured 
by sympathy, reacts perniciously on the heart, a pathological condition quite 
sufficient to explain the death of the patient. Such cases are, however, 
rare in this country, as not one has occurred in my own practice. Much 
oftener the fate of the patient is postponed, and made at last to depend on 
other lesions. 

When the effusion is very great, the inflammation may subside, leaving 
the pericardial sac distended with turbid lymph, which concreting upon 
the surface of the heart contracts around and compresses it, while the 
constant reaction of the pericardium tends still further to restrain and 
enfeeble its action, leading ultimately to atrophy of the organ, of which 
we have in the Pathological Museum of the University of Louisville, a 
very remarkable specimen. Oftener, however, the serous portion of the 
lymph is absorbed, and when the pericardial surfaces rough with deposits 
of fibrine come into contact, reproducing the friction sound for a short 
time, they adhere and the organ is thus firmly enclosed in a tunic, which 
by its shrinkage becomes a cause of permanent embarrassment to its func- 
tions, and at last produces death in a manner to be hereafter pointed 
out. The surfaces, however, do not always adhere throughout their whole 
extent, and the adhesions are sometimes of such length as to admit of a 
limited motion of the organ within its capsule. 

The liquor sanguinis is not the only product of pericarditis. The secre- 
tion of pus is by no means an uncommon event. This is sometimes found 
mingled with lymph, but in other cases it exists in large quantities, un- 
mixed with any other secretion, the surface of the sac being shaggy with 
deposits of lymph. The favorable absorption of such a quantity of hetero- 
logous fluid is not to be expected, and its contact with the heart, indepen- 
dently of all mechanical injury, exerts on that organ a pernicious influence. 
When the pericardium is thus distended either by liquor sanguinis or pus, 
the sounds and impulse of the heart are -of course feeble from being trans- 
mitted through such a mass of thick fluid ; the pulse is generally weak and 
irregular, the dulness of the precordial region is extensive, and sometimes 
there is a bulging out ; the dyspnoea under exercise is extreme, and the 
aspect of the face bloated, and sometimes livid. Of course in this stage 
of the disease the fever will have ceased. 

What has been said relates to acute pericarditis. It remains now to say 
that subacute or chronic forms of the disease are much more common, and 



INTERIOR VALLEY OF NORTH AMERICA. 953 

in the end not less dangerous. An acute may become a chronic case ; but the 
inflammation may have been subacute from the beginning. It may even 
have been so mild that little else than serum was thrown out, when it would 
possess the character and receive the name of hydropericardium. Subacute 
inflammations may, however, occasion the slow effusion of both lymph and 
pus (the latter, it appears, to a greater extent than the acute form of the 
disease), and gradually bring about the anatomical lesions which have been 
described. The rise and progress of such cases are insidious, and their 
diagnosis difficult and uncertain. As they are distinguishable in their early 
stages from acute cases, only by the greater mildness of the symptoms, no 
special diagnosis can be given. In their advanced stages the lesions and 
symptoms dependent on them are the same as in the latter stages of the 
acute form of the disease. 

Pericarditis may be complicated with endocarditis, pleurisy, and pneu- 
monia, the sigus of which combinations can be best presented under those 
respective heads. 



SECTION IV. 

ENDOCARDITIS : SYMPTOMS AND PATHOLOGICAL CHARACTERS. 

When the inflammation is endocarditic, the hyperemia of the lining 
membrane, and the subjacent cellular and muscular substance, together 
with a greater or less retention of blood in the cavities of the heart, from 
interrupted egress, gives increased size to the organ and consequent dulness 
under percussion, beyond the ordinary precordial region. This dulness may 
be distinguished from that attendant on pericarditis with effusion into the 
sac, by the sounds and impulse of the heart being more distinctly perceived, 
from the organ's being nearer the parietes, and by the pulse being generally 
weak,' small, and extremely frequent, from the interrupted exit of blood, 
although the action of the heart is powerful. It may also be distinguished 
from the dulness attendant on permanent hypertrophy, by the suddenness 
and recentness of its occurrence. The pain is in general less acute than 
that of pericarditis, but the oppression, anguish, anxiety, and sense of suffo- 
cation are greater. Flexion of the chest increases these symptoms as much 
as in pericarditis, but pressure over the intercostal muscles is better borne 
than in that affection, because it does not act upon the inflamed membrane. 
The pathognomonic symptom remains to be mentioned ; a blowing or bellows 
murmur, which sometimes assumes a metallic, a sawing or rasping sound, 
which marks or obscures one or both the normal sounds of the organ. As 
long as the valves of the heart remain healthy and perform their functions 
with regularity, these sounds are not heard, their occurrence then is evidence 
of valvular lesion, and this results from the inflammation of the membrane 
of which they are the duplicatures. 



954 THE PRINCIPAL DISEASES OP THE 

Every part of the pericardium performs the same function, and hence its 
inflammation is in general spread equally over the whole ; but the lining 
membrane of the heart performs unequal function. In the cavities of the 
organ it merely protects the muscular substance from the direct impress of 
the blood, and gives a polished surface for the fluid to move over ; but at 
their orifices, where it is folded into valves, it not only serves these pur- 
poses, but additionally permits the blood to pass, and then prevents its 
regurgitation. Few parts of the body indeed perform a more incessant 
function, and none are more liable to have it increased, seeing that every 
cause which accelerates the circulation, quickens the action of the valves. 
Thus we might believe, a priori, that endocarditis would direct itself on 
the valves, rather than on the general surface of the cavities, and if we 
may rely on the revelations of morbid anatomy, such is the fact. In every 
acute inflammation of the endocardium, coagulating lymph is no doubt 
thrown out upon the free surface of the membrane, much of which is imme- 
diately washed away by the torrent of the circulation j when, however, the 
inflammation is so intense as to roughen the surface, particles of fibrine begin 
to adhere, and rapidly augment its capacity for fixing other particles. Thus 
begins that valvular lesion which constitutes the specific anatomical cha- 
racter of endocarditis, and generates the pathognomonic bellows sound. 
But all the fibrine which thus accumulates on the valves is not secreted by 
their inflamed membrane. The blood is in a state of hyperinosis, and at 
all times a foreign body projected into its current through an artery will 
collect shreds of fibrine. The roughened valves cannot fail to arrest por- 
tions of that element as it flows along, and this operation may continue long 
after the inflammation has ceased, and the secretion of lymph been termi- 
nated. Minute and curious pathological anatomists, with ample hospital 
opportunities, may trace out many varieties of valvular lesion thus pro- 
duced, but to the practical physician that kind of knowledge is not essen- 
tial. It is sufficient for him to know that the valves may lose their normal 
form and facility of action; may suffer agglutination to each other; may 
become loaded with tufts of fibrine called vegetations, or with lumps of the 
same element; may be torn; may be so contracted as permanently to dimi- 
nish the size of the orifices ; — in short, may, from change of structure, not 
only retard the passage of blood into, through, and from the heart, but fail 
to prevent its regurgitation under the reaction of the arterial system. In 
any of these conditions we have, when the ventricles contract, the bellows- 
sound, or some other. kind of murmur equally indicative of valvular de- 
rangement. When the physician hears these sounds he must not, as a 
matter of course, pronounce the cause of them permanent, and regard the 
case as hopeless, for mere swelling, or the slightest roughening of the 
valves may occasion them, and such a condition is remediable. The length 
of time they have lasted must, in general, determine his prognosis. When 
the ear or hand is applied to the precordial region, under such circum- 
stances, a thrill or vibration is often distinctly perceptible under every 



INTERIOR VALLEY OF NORTH AMERICA. 955 

systolic contraction. If the patient be brought under any exciting emotion, 
and made to exert his muscular system for a moment, this thrill and the 
valvular sounds will become much more distinct; and if under such cir- 
cumstances the patient is made to hold his breath, the most inexperienced 
ear will recognize them to a satisfactory degree. 

Endocarditis may attack all the orifices of the heart, and derange all the 
valves j but observation has shown that the left side is far oftener affected 
than the right, and its semilunar valves more frequently than the mitral. 
It is not easy to determine which side of the organ is the seat of the inflam- 
mation when one only»is affected; but happily in this, as in some other 
forms of disease, a decision of that kind is not a necessary prerequisite to 
the treatment. 

Endocarditis may prove fatal in a few days. A great tumefaction of the 
valves may carry extreme derangement into the circulation ; the intensity 
of the inflammation may produce a deep and dangerous lesion of innerva- 
tion in the heart ; the sympathy of the brain may be intense, and its de- 
rangement of function further increased by the impeded return of its 
venous blood, from retarded circulation through the heart; and finally, we 
suppose that pus is sometimes secreted, and mingling with the blood em- 
poisons the organism — pathological causes sufficient to occasion early death. 
The majority of cases, however, have not this severity, and soon declining 
into a subacute grade, assume a chronic form. Many cases indeed are of 
this kind from the beginning, and not a few are confounded with mere 
nervous palpitations. Whatever may be the grade of inflammation, its 
ultimate consequences may be equally fatal, as it eventuates in the same 
lesions of structure. Chronic inflammations, moreover, sometimes ascend 
into the aorta, where they occasion deposits of lymph in or beneath the 
lining membrane, and not unfrequently produce ulceration, a lesion which 
is sometimes found in the cavities of the heart and on the valves. The 
lymph deposited on and near the valves, if not absorbed, passes into the 
condition of fibrous, fibro-cartilaginous, cartilaginous, and osseous tissue, 
thus increasing their immobility or irregularity of action long after the 
inflammation has ceased. 

Permanent valvular lesions are the pathological cause of extensive and 
fatal derangements, such as hypertrophies and dilatations of the heart, cere- 
bral and pulmonary lesions, both functional and structural, hepatic disorders, 
and dropsies of the extremities, pleura, and pericardium, — effects to be 
hereafter considered in connection with the sequelae of pericarditis. 



SECTION V. 

SYMPTOMS AND EFFECTS OF CARDITIS. 

However laudable the ambition of those, who, haviDg ample oppor- 
tunities, in great hospitals, aspire to establish the differential diagnosis of 



956 THE PRINCIPAL DISEASES OF THE 

carditis, it would be labor lost for the country or village practitioner to aim 
at such nicety. He should be able to detect cardiac inflammation, and even 
declare in which of the membranes it is seated, but is not bound to decide 
on the degree in which the intervening muscular substance participates. In 
fact the most experienced and eminent cultivators of this branch of diag- 
nosis have as yet been unsuccessful; and it seems to be generally admitted, 
that as inflammation of the muscular is always complicated with that of the 
membranous tissues, its peculiar symptoms will, perhaps, never be elimi- 
nated from the mass. 

We cannot doubt that carditis, whether acute or chronic, is a grave 
disease. Three of its lesions deserve to be noticed. 1st. The secretion of 
lymph. When this takes place in the cellular tissue of the organ, should 
the case not prove fatal, the analogous structure, by contraction, so acts on 
the muscular fibres as to occasion atrophy, while the new structure, obeying 
the laws of its organization, passing successively through the different 
grades of induration — fibrous, cartilaginous, and osseous — comes at last to 
present the transformations which often attract our attention in the dissect- 
ing-room. They generally occupy one or several limited portions of the 
organ. 2d. Pus is sometimes secreted. It may be either infiltrated into 
the tissue, or collected into an abscess. When this opens through the 
endocardium, an ulcer is formed, which may ultimately lead to perforation 
or rupture of the cardiac walls, and a fatal escape of blood into the cavity of 
the pericardium. Professor Harrison met with a case in which a great 
number of small ulcers, excavating the outer substance of the heart, dis- 
charged their pus into that capsule.* 3d. The muscular tissue may soften, 
under either acute or chronic inflammation, and, at last, be ruptured. 

In the year 18*28, I witnessed a case illustrative of this termination, and 
of the symptoms attendant on chronic carditis affecting a part of the heart 
only.f 

Pt. B., a native of England, aged sixty-seven, of large stature and rather 
inclined to corpulence, but of an athletic temperament, sober in his habits, 
and for more than forty years, a laborious cordwainer, had been for half his 
life afflicted with some variety of psoriasis on both arms. Eighteen months 
before his death, it left its original seat and attacked his head and face, 
causing the loss of his eyebrow, and giving to the affected skin a sooty hue. 
After the lapse of a year it moved down to his chest, from which it disap- 
peared before his death. Soon after fixing itself on this part, he began to 
experience paroxysms of pain in his heart. What other symptoms existed 
I cannot state, not at that time being his physician • but I learned that he 
was treated with stimulants and narcotics. Two months after this period, 
on being called to see him, his respiration was somewhat embarrassed, but 
he had little or no cough; his pulse was intermitting, rather increased in 
frequency, but not very strong; he had a slight swelling of the abdomen, 

* Gross's Path. Anat., 2d Ed., p. 492. f West. Jour. (Cm.), vol. ii. p. 337. 



INTERIOR VALLEY OF NORTH AMERICA. 957 

and considerable oedema of the feet and legs, which were habitually cold. 
His tongue was clean, and his bowels easily moved; but his appetite was 
gone, and he frequently vomited. His spirits were habitually depressed, 
and he often shed tears. In the day he slept a little ; but his morbid vigi- 
lance and restlessness at night were distressing in the highest degree, and 
accompanied by a kind of delirium. His chest, under percussion, sounded 
well ; and, through the stethoscope, a feehle respiratory murmur could be 
heard over every part. On resorting to the instrument, with a view to the 
movements of the heart, I could distinctly perceive its intermissions ; but 
neither its sound, impulse, nor volume, seemed to be remarkable; the two 
former were, indeed, rather weak. He could lie on either side, and on his 
back, in a horizontal posture, without difficulty. 

During the treatment to which I subjected him, the dropsical symptoms 
disappeared, but all the rest gradually increased. He was bled once ; but 
no benefit followed, though the blood was sizy. Up to the close of life, his 
most constant and characteristic symptoms were habitual, intermitting 
pulse, occasional vomiting, epigastric anxiety, dyspnoea, deep depression of 
spirits, debility, and confusion of mind, taciturnity, and morbid vigilance 
alternating with coma. He was long in articulo mortis, with distressing 
agitation of the heart and convulsive action of the muscles of respiration, 
especially the diaphragm. 

Dissection. — Permission was granted to examine the contents of the 
chest and abdomen ; but circumstances limited us to a period of time too 
short for a perfect search into their condition. 

On proceeding to open the thorax, the cartilages of several ribs, on each 
side, were found in a state of ossification, and required the use of the saw. 

The lungs did not collapse, and seemed to be universally emphysematous. 
As far as examined, they were neither tuberculous nor hepatized. No pleu- 
ritic adhesions existed ; but in examining for them, I was surprised to find 
a quantity of dark, fluid blood in each side of the chest. In the right, it 
scarcely amounted to an ounce, but in the left there was, by estimate, more 
than two ounces. 

The heart was enveloped in an extraordinary quantity of fat. It was of 
the common size ; but far from the ordinary shape, its apex being enlarged 
and tuberous. It was evident from external inspection that the pericar- 
dium contained no water; and on cutting through that membrane, with a 
view to turn out the heart, it was found adhering to that organ throughout 
its whole extent, indicating a universal pericarditis. At its junction with 
the pleura of the diaphragm, the effects of inflammation were equally ob- 
vious, and extended to some distance on the surrounding parts of that organ. 
At the point of union between the two, the pericardium had given way, and 
about the .aperture there was a quantity of red, pulverulent, pulpy matter, 
which was the muscular substance of the heart transformed by disease. In 
cutting upwards from this place at right angles to the septum, so as to divide 



958 THE PRINCIPAL DISEASES OF THE 

the organ into halves, the whole extent of the diseased structure was ex- 
posed to view. For more than an inch, the parietes of each ventricle, 
together with the partition, had lost its fibrous texture, was softened, and 
flaky, or laminated, so that the finger passed readily through it in all direc- 
tions. The transformation was greatest at the apex, indicating that it had 
commenced in that part. Its termination above was not pointed out by any 
line of demarcation, and the morbid action which occasioned it had con- 
tinued to advance upwards to the time of death. The coluumsecarneae had 
experienced the fate of the parietes, but beyond the limits of the disor- 
ganized part they were entire. Both they and the parietes, however, were 
paler and more relaxed than in the healthy heart. The valves were free 
from degeneracy. 

In a partial examination of the abdominal viscera, no morbid appearance 
was found. 

Gangrene. — This is so rare a termination that but few pathological 
anatomists have ever seen a case. We need not be surprised that this 
muscle is riot easily gangrened, since the lesions of the functions of the 
heart must in general destroy life before the inflammation can advance to 
gangrene. 



SECTION VI. 

CAUSES OF CARDIAC INFLAMMATION. 

We may now reunite the study of the three varieties of cardiac inflamma- 
tion, which in their specific diagnosis and anatomical lesions required to be 
considered separately, but in their etiology and treatment may be conve- 
niently associated. 

The causes of cardiac inflammation may be referred to three different 
heads, physiological, accidental, and pathological. 

A. Physiological. — 1. Age, .Sex, and Temperament. — On the whole, 
from childhood up to the thirtieth year, this form of inflammation is more fre- 
quent than after that period. It is said again to become more frequent in 
advanced life, but it is then, I presume, generally a secondary affection con- 
sequent on slowly induced organic diseases. My own experience concurs 
with that of others in regard to its greater frequency in the male than the 
female sex. The latter often have mere nervous palpitations under the 
influence of causes, which in the former awaken inflammation. Hence the 
signs of cardiac disease are of graver import in men than women. 

The temperament which most predisposes to this affection is the san- 
guineo-bilious or the sanguineo-nervous; but even the lymphatic does not 
bestow immunity if the individual be exposed to the action of energetic 
remote causes. 



INTERIOR VALLEY OF NORTH AMERICA. 959 

2. Muscular Exertion. — The muscular system of animal life acts physio- 
logically upon the heart. In loud and long speaking, violent running, 
jumping, climbing, swimming, lifting great weights, and carrying heavy 
burdens, the blood is returned rapidly upon the heart, and interrupted in its 
passage through that organ. In these efforts respiration is irregular, in 
locomotion it is hurried, in lifting heavy weights it is suspended, the indi- 
vidual always making the effort after a deep inspiration. Now while a free 
expiration and subsequent suspension of breathing exerts but little influence 
on the fulness, force, frequency, and regularity of the pulse, a full inspira- 
tion retained, increases the frequency of the pulse twenty-five per cent., re- 
duces its volume until the artery at the wrist feels almost empty, and ren- 
ders the action of the heart irregular. It would appear from these facts that 
when the lungs are greatly inflated the passage of blood through them is 
impeded. Thus in muscular effort accompanied by deep inspiration, two 
causes of accumulation in the right cavities of the heart, and in the coronary 
veins co-operate, to wit, a more rapid return of blood from the muscular sys- 
tem, and a retarded transmission through the lungs. Under this combined 
influence, if the heart should be organically unsound, it may suffer a fatal 
lesion, but our present inquiry relates to its inflammations. It cannot be 
doubted, I think, that the being subjected, frequently, to this distension of 
its right side, and inanition of its left, the circulation through its nutrient 
vessels being at the same time suspended, must of necessity disturb its vital 
properties, and predispose it to inflammation ; and in this manner I suppose 
we .may explain the well-known fact, that the efforts we are considering, are 
among the physiological causes of cardiac inflammation. 

3. Constrained Postures. — Nearly connected with these causes, are cer- 
tain constrained and sedentary postures, which act on the heart and great 
vessels mechanically. Tailors, shoemakers, and clerks, who bend long over 
the writing-table, are most obnoxious to injury from these causes; which 
seldom, I suppose, produce acute inflammation, and are oftener enumerated 
among the causes of organic disease than inflammation. They do, in fact, 
ultimately generate structural derangements, which, however, are only the 
consequences, as I suppose, of previous subacute inflammation. I have often 
seen a tailor slowly walking the streets of Cincinnati, with bloated visag# 
and purple lips, but did not learn the early history of his case. I have 
already given that of an aged cordwainer, of the same city, in whom chronic 
carditis produced softening of the heart with fatal hemorrhage into the peri- 
cardium. The effects of these and kindred occupations will account in part 
for the greater prevalence of cardiac inflammation in old and populous cities 
than in the country. 

4. Cold. — Another physiological influence may be assumed as a cause of 
this inflammation. I refer to cold, or cold and moisture, so applied to the 
surface of the body as to repel the blood from the exterior parts, and thus 
distend the great vessels and the cavities of the heart. This influence, 



960 THE PRINCIPAL DISEASES OP THE 

moreover, as we have seen in the chapter on the general causes of the 
phlegmasia, acts, likewise, through the innervation. That it is one of the 
most common causes of internal inflammation cannot be doubted, and that 
it may excite that disease in the heart must be admitted. But it is chiefly 
when the exposure follows long or violent effort, which has not only predis- 
posed the heart to disease, but raised the temperature of the body and ex- 
cited perspiration, that we witness the power of exposure in the development 
of cardiac inflammation. 

5. Passions and Emotions. — The heart by its nerves is not only made to 
sympathize with every organ of the body, when diseased, but is brought 
under the influence of the passions and emotions. The cheerful sustain it, 
the gloomy and depressing reduce its vital energy, and sometimes quicken 
its pulsations, rendering them at the same time irregular; the angry and 
resentful irritate it into passion, increasing the frequency and suddenness of 
its contractions, augmenting their force, and destroying their regularity. 
The frequent recurrence, or continued action of any of these causes of 
cardiac perturbation, might be expected to predispose to, or excite inflam- 
mation, and such is well known to be the fact. In this way we may per- 
haps, in part, explain the great number of cardiac inflammations in large 
cities, and especially among the poor, who, from their circumstances, are 
liable to deep and protracted emotions, while they are still further sub- 
jected to the sinister influence of constrained attitudes, fatigue, and exposure 
to cold. 

B. Accidental. — 1. Falls and Blows. — A fall upon the precordial 
region may be followed by cardiac inflammation, either acute, or slowly 
developed under the added influence of other causes, as exposure to cold, 
violent exertion, or strong mental emotion. A blow on the same part may 
produce the same effect, but is perhaps less serious than the same force 
applied to the epigastrium, especially if it should be directed upwards. 
The fatal effect of that kind of blow is well known, and two explanations of 
the effect have been offered : 1st, its influence on the stomach; 2d, on the 
solar plexus ; but I am disposed to regard its effect upon the heart as much 
more serious than either. A blow below the ensiform cartilage and the 
•cartilages of the left ribs, unless it should be directed obliquely downwards, 
cannot fail to injure the heart, especially if it occur at the moment of a 
deep inspiration, when the descent of the diaphragm drags that organ down 
as it were to meet the violence. 

2. Punctured wounds of the pericardium and of the heart, when they do 
not penetrate its cavities, are not necessarily and immediately fatal, and are 
therefore causes of inflammation, which must inevitably follow. Even 
when they enter the ventricles, if not extensive, the patient, as observation 
has shown, may live for a time amply sufficient for inflammation to be de- 
veloped.* Gunshot wounds, less likely than punctured to prove fatal by 

* Diet, des Scien. M6d., torn. 43. 



INTERIOR VALLEY OF NORTH AMERICA. 961 

hemorrhage, are also a cause of inflammation. A case of this kind, in 
which no less than five small shot perforated the parietes of the organ and 
sojourned in its cavities, was reported by Dr. Leonard Randal, of Tennessee, 
in the year 1828.* The patient, a negro boy, fifteen years old, lived sixty- 
seven days after receiving the contents of a shot-gun on the left side of the 
sternum, about an inch and a half above its lower extremity. The heart 
was greatly depressed in its force, and very irregular in action for a week, 
when the external wound began to granulate, and in a month was cicatrized. 
The patient was now able to walk about, and seemed to be getting well, 
when, from eating a hearty meal, thoracic inflammation ensued, followed by 
hectic fever, and in five months he died. On dissection, the lungs, which 
had received many of the shot, were found extensively diseased. The peri- 
cardium showed adhesions to the heart and. 'also to the pleura. The five 
shots had penetrated the organ about one-third of the distance from its base 
to its apex, and the wounds they had made were cicatrized. The heart 
appeared to be enlarged, and some portions of its parietes were almost car- 
tilaginous. In the right auricle there were two detached shot. It did not 
show any lesion of structure. In the right ventricle, on which the enlarge- 
ment of the heart depended, there were three also lying loose. The internal 
surface was of a dun color, and presented a thickening of the membrane, 
with a roughness resembling that of an ox's tongue. The state of the valves 
is not mentioned in the report. In this case there had been inflammation 
of all the tissues of the heart. How long the patient might have lived 
with the five shot in the right cavities of his heart, if his lungs had not 
been extensively diseased from other parts of the same charge, cannot be 
decided. 

C. Pathological Causes. — The causes referred to the two preceding- 
heads generate primary cardiac inflammation — those which belong to the 
present give us secondary or consequential cases, which are much more 
numerous. 

1. A relation of mutual influence exists between every organ of the body 
and the heart. If any one be in pain, without hyperemia, the heart sym- 
pathizes, and in general manifests its suffering by diminished force and 
increased frequency of contraction, — the pulse of irritation. If an organ be 
in the opposite state, — that of inflammatory hypersemia, — the sympathy of 
the heart becomes febrile, and is displayed in augmented energy, quickness, 
and frequency of contraction. This is the condition into which it is thrown 
by all the phlegmasia, and especially those of important organs. The 
reaction of the heart in these cases is not directed specifically upon the 
organ which roused it into unnatural action, but upon the whole, as it con- 
sists simply in giving to the blood a greater velocity and momentum. Thus 
the various organs affect the heart through the innervation, while it affects 
them through the circulation. At present, we are only concerned with the 

* Western Jour. (Cincinnati), vol. ii. p. 329. 
VOL. II. 61 



962 THE PRINCIPAL DISEASES OF THE 

former. To what extent, then, is this sympathy a source of cardiac inflam- 
mation ? It must, I think, be admitted that, a priori, we should expect to 
see such inflammation very often produced in this manner, and yet such 
does not appear to be the case, for, in the phlegmasia of most of the organs, 
the heart will continue in a state of high and sustained excitement for many 
days without being inflamed, as appears not only from the absence of the 
signs of cardiac inflammation, but from the quiet and healthy action into 
which that organ falls, as soon as the distant inflammation which excited it 
is reduced. We may say then, as a general fact, that the ready and uni- 
versal sympathy of the heart with inflamed organs is not a cause that raises 
inflammation in it. 

2. But there are exceptions to this conclusion. It is now well known 
that inflammation of the fibrous tissues, frequently attacks the correspond- 
ing tissues of the heart, after having prevailed for a time in the extre- 
mities. Sometimes indeed it appears first in that organ, but such instances 
are rare. In many cases, the affection of the joints continues after that of 
the heart has become established, giving it the character of a true sympa- 
thy; in other patients the articular inflammation ceases as the cardiac set 
in, giving it the character of a metastasis. Now, there is no special sym- 
pathy between the joints and heart, and rheumatic inflammation is essen- 
tially unsettled. In its wanderings, it attacks the dura mater, diaphragm, 
sclerotic coat of the eye, and other white fibrous textures, as well as the 
heart, but not so often. In fact, it can scarcely be said to conform to the 
laws of sympathy, but to consist essentially in a floating irritation. But 
not to dwell on the language appropriate to this pathological condition, we 
may regard a rheumatic diathesis as the immediate pathological cause of a 
large proportion of the cases of cardiac inflammation which present them- 
selves in practice. In childhood and youth, it is perhaps oftener seated in 
the lining membrane than the other tissues ; but they may be affected at 
that early period, while it is not exempt at a more advanced era. As a 
general fact, the rheumatic inflammation of the heart is of the same grade, 
acute or subacute, with that of the joints. In many instances the heart 
becomes affected some years after the articular inflammation has entirely 
ceased. 

3. Another and more obviously sympathetic origin of cardiac inflamma- 
tion is to be found in the stomach. The effects of stimulating food, drinks, 
and medicines, on the movements of the heart, assure us of the lively asso- 
ciation which that organ maintains with the stomach. Whatever raises or 
depresses the excitement of that organ, affects the heart in a corresponding 
way. In dyspepsia, unaccompanied by inflammation, the heart becomes 
either feeble and sluggish, or irritable, convulsive^ and frequent in its con- 
tractions. In chronic gastritis or inflammatory dyspepsia, the heart sympa- 
thizes, and is liable to become the seat of a subacute inflammation, which 
may be mistaken for simple irritability. I am quite convinced that many 



INTERIOR VALLEY OF NORTH AMERICA. 963 

of the hypertrophies of that organ which present themselves to us in this 
country, have this remote origin. They are, strictly speaking, tertiary affec- 
tions. The gastritis produces carditis, and it occasions hypertrophy. The 
second results from sympathy, the third from valvular or pericardial lesion. 

4. In chronic hepatitis the heart is deeply affected, but not often with 
inflammation. The defective elimination of the elements of the bile from the 
blood, or their absorption, from obstructed excretion, generates a state of con- 
stitutional depression and morbid sensibility, in which the heart deeply par- 
ticipates ) but this condition rather opposes than promotes inflammation ; 
nevertheless, a vigilant physician will not be unmindful of the possibility 
that cardiac inflammation of a low grade may be developed under such cir- 
cumstances. 

5. In pleurisy and pneumonia, the inflammation often extends, by conti- 
nuity or contiguity of texture, to the pericardium. Obstructed pulmonary 
circulation may contribute to the same effect; and the intimate association 
of function between the heart and lungs may lead to a sympathy of the 
former with the latter. The supervention of cardiac inflammation on pul- 
monary is disclosed by post-mortem inspections, rather than by the symp- 
toms during life, which are so mixed up with the pulmonary as to render 
analysis difficult. We must not suppose, however, that in all cases of pul- 
monic and cardiac inflammation combined, the latter is occasioned by the 
former, for the same remote cause may simultaneously excite both. 

6. Pertussis now and then produces cardiac inflammation. In some cases, 
this may be the result of sympathy, in others of disturbed respiration. 

7. The more formidable eruptive fevers, small-pox, scarlatina, and mea- 
sles, are occasionally followed by inflammation in some of the tissues of the 
heart, as in other internal organs; an effect dependent chiefly perhaps on 
the sudden refluxes of blood from the circumference of the body, so common 
in those diseases. 

8. The last pathological cause that I shall mention, is organic disease of 
the heart itself. Whether produced directly or remotely by inflammation, 
or the effect of lesions of nutrition only, organic derangements are themselves 
finally the cause of inflammation. Thus, in their advanced and fatal stages, 
that condition is liable to arise — a fact of which all who treat such cases 
ought to be aware. 

I. We have seen that persons liable to rheumatism are very often affected 
with cardiac inflammation : between rheumatism and gout, there are many 
close analogies. In gout, there is a great development in the blood of lithic 
acid, which, seizing on the soda of that fluid, forms the tophaceous deposits 
of the affected joints, and it seems highly probable that there is an abnor- 
mal development of some acid, probably the lactic, in rheumatism. This, 
indeed, is asserted by Dr. Budd ;* and, assumed as a fact by Dr. Furnival,f 
has led him to administer alkalies in acute rheumatism, as a means of avert- 
ing inflammation of the heart, a practice which he has found eminently suc- 

* Library of Med. vol. iv. p. 212. f London Lancet, 1844. 



964 THE PRINCIPAL DISEASES OF THE 

cessful. Simon* informs us that in this disease there is excess of lactic 
acid. We may then admit among the probable causes of cardiac inflamma- 
tion this morbid condition of the blood. 

D. Causes connected with the Blood. — 2. Observation and experi- 
ment have demonstrated that many active substances, brought into contact 
with the pulmonic and alimentary mucous membranes, find their way into 
the veins, and are carried to the heart. Of their power, when thus applied, 
to excite endocarditis, but little is as yet known. That alcohol, when an 
ingredient of our beverages, is thus introduced, cannot be doubted; and 
intemperance is enumerated by many of the systematic writers among the 
causes of cardiac inflammation. That it excites gastritis and hepatitis there 
can be no doubt, but whether the heart becomes affected from sympathy with 
the stomach and liver, or from the contact of alcohol with its lining mem- 
brane, is not known ; perhaps in both modes. 

3. Four quasi pathological conditions of the blood (not dependent on 
foreign matters introduced into it), deserve to be mentioned here. They 
are excess and deficiency of fibrine, and excess and deficiency of red cor- 
puscles. How far the first by its action on the endocardium may contribute to 
promote inflammation is not known ; but we are not at liberty to overlook the 
fact that in acute articular rheumatism, the absolute quantity of fibrine is in 
general greater than in any other disease, and no other (all others taken 
together) so often excites endocarditis. Deficiency of fibrine appears to be 
generally connected with reduced energy in the heart, which indicates that 
it cannot be a direct cause of inflammation. Excess of red corpuscles (con- 
stituting plethora) gives as we have already seen a full pulse, and often ren- 
ders the action of the heart irregular, but such symptoms do not necessarily 
imply inflammation; such a condition would however seem to be a predispo- 
sition to that disease. Deficiency of corpuscles, or chlorotic blood, is ac- 
companied by great irritability of the heart, and is perhaps never a direct 
cause of inflammation j but irritability often favors the production of in- 
flammation, and may therefore sometimes be a predisposing cause to that 
state in the heart. 



SECTION VII. 

SEQUELS OF CARDTAC INFLAMMATION. 

The immediate or proximate- effects of this inflammation have been indi- 
cated under the appropriate heads. Some of the secondary and tertiary 
have also been referred to incidentally. It may be useful to present the 
whole in a single view. 

1. Proximate Lesions of Pericarditis. — Partial or general adhesion of 
the membrane to the heart, and to the pleura — collections of serum, lymph, 
pus, and blood in its cavity — ulceration. 

2. Proximate Lesions of Endocarditis. — Softening of the membrane, 

* Chemistry of Man, p. 377. 



INTERIOR VALLEY OF NORTH AMERICA. 965 

especially its valvular folds, ulceration, laceration, deposits of fibrine on the 
valves, agglutination, contraction, immobility, vegetations, cartilaginous, 
and osseous transformations. 

3. Proximate lesions of the Muscular Substance. — Suppuration, ulcera- 
tion, aneurismal dilatation, softening, laceration, induration, gangrene. 

If these immediate consequences of inflammation were the causes of all 
the organic degeneracies to which the heart is obnoxious, it would be natural 
and convenient to trace them out under the present head ; such, however^ 
not being the case, I prefer to bring the whole together under a different 
title, after the subject of inflammations has been disposed of, and will, there- 
fore, in this place only enumerate such as are produced by the lesions just 
named. 

They are chiefly hypertrophy and dilatation, separate or combined, in one 
or all the cavities of the organ, consequent on which as tertiary affections, 
are pulmonary inflammation, hemoptysis, and habitual dyspncea, cerebral 
irritation, headache, vertigo, inflammation, apoplexy, palsy, hypochondriasis, 
melancholy, and suicidal monomania, biliary derangements, hydropic effu- 
sions, especially anasarca, hydrothorax, and hydro-pericardium, lastly gan- 
grene of the extremities. 

It is only necessary to recollect, that this frightful catalogue of diseases, 
organic and functional, may be the consequences of a few days of undis- 
covered or unskilfully treated cardiac inflammation, to realize the deep im- 
portance which attaches to a knowledge of its diagnosis, and to the timely 
application of remedies. 

SECTION VIII. 

CURE OF CARDIAC INFLAMMATION. 

After what has been said in a preceding chapter, on the indications of 
cure and means of fulfilling them, in the phlegmasia generally, the treat- 
ment of particular species need not detain us long. This is especially true 
of that now under consideration, the efficient remedies for which are few 
and near at hand. 

1. Venesection. — All experience declares that this is the first of our reme- 
dies, both in point of time and importance for acute cardiac inflammation. 
In deciding on it we must not be governed by the state of the pulse, for it 
will often be small, compressible, and weak, when the necessity for the 
lancet is most urgent. The first bleeding should be copious, but not carried 
to the extent of syncope, unless we are assured that the inflammation does 
not exist in the endocardium, for if it should, the temporary stasis of the 
blood in the heart would favor the deposit of fibrine on its valves. In cases 
of moderate intensity a single venesection may be sufficient; in the violent, 
the operation may be repeated once or twice. To the last the blood will be 
found sizy, especially when the disease is of a rheumatic origin. Indis- 



966 THE PRINCIPAL DISEASES OF THE 

pensable as this remedy is, the limit of its employment is less extended 
than in some other phlegmasia?, for the reason that the sudden loss of blood 
augments the irritability of the heart, injuriously increasing its action 
while it diminishes its power. 

2. Local Bleeding. — The contiguity of the heart to the parietes of the 
chest, seems to favor the beneficial influence of cups or leeches, and after 
the first or second bleeding they may be made to supersede the lancet, 
except in cases of great intensity, occurring in vigorous constitutions and 
unconnected with a rheumatic diathesis. 

3. Blisters should never precede local bleeding, nor be applied very early 
in the disease, for their irritation might prove aggravating instead of revul- 
sive. The discharge which they induce gives them an advantage over sina- 
pisms. When the disease is of rheumatic origin, blisters may be advanta- 
geously applied over or near to the parts which have been formerly affected. 

4. Purging to the extent of evacuating the existing contents of the 
stomach and bowels, should be effected after the first bleeding; but a con- 
tinued repetition of cathartics as a means of reducing the vascular excite- 
ment is not judicious. 

5. Alterants, of which calomel and tartar emetic should be preferred, are 
among the most important remedies. Of the whole, calomel is the most 
efficient and may be administered in liberal doses at stated intervals until 
a salivation commences or the inflammation gives way. When tartar emetic 
is used, a quantity sufficient to nauseate may be prescribed, say one-fourth 
of a grain combined with each portion of calomel. The debilitating action 
of this medicine on the heart is greater than that of calomel, nevertheless 
its control over cardiac inflammation is less. Should pneumonia be compli- 
cated with the carditis the value of tartar emetic will be greater. 

6. Saline Sedatives. — Nitrate of potash is not to be overlooked. Tartar 
emetic may or may not be added to its solution. It is well adapted to cases 
accompanied with a burning heat, or in which the secretion of urine is much 
diminished. When the inflammation is of a rheumatic origin, according to 
the experience of Dr. Furnivall, the carbonate of potash and other alkalies 
may be administered with benefit. They appear to act by neutralizing the 
superabundant acid in the blood. 

7. Narcotic Sedatives. — Digitalis is a valuable medicine in this inflam- 
mation. I have always used the tincture as acting more on the heart and 
less on the kidneys than the infusion. It may be advantageously combined 
with a solution of tartarized antimony. It will not be proper to give more 
than a drachm in twenty-four hours, and that quantity cannot be safely con- 
tinued for more than three or four days. The irregularity of the heart's 
action, when inflamed, deprives us of one of the means of judging when the 
digitalis has been pushed far enough, and renders caution necessary. In the 
declining stages of the disease, and during convalescence, the medicine, in 
moderate doses, will be found beneficial, as subduing the remains of inflam- 






INTERIOR VALLEY OF NORTH AMERICA. 967 

matory action. Colchicum may be substituted for digitalis, and is no doubt 
preferable to it in rheumatic carditis. In such cases it may indeed be 
regarded as an appropriate medicine ; and its influence on the heart, under 
an excessive administration, is less dangerous than that of digitalis. It acts, 
moreover, on the mucous membrane of the bowels, producing revulsion, -and 
serous secretion. 

But of all narcotic sedatives, opium is the best, fulfilling, beyond every 
other medicine, the important indication of allaying the morbid irritability 
of the heart, and moderating its excessive action. This violent action aggra- 
vates the inflammation which occasions it, and deserves, on that account, the 
anxious attention of the physician. It is a great mistake to suppose that 
opium should not be administered till the inflammation is subdued. After 
one bleeding, and the operation of a single cathartic, the administration of 
opium may commence, and should be continued throughout the whole attack. 
All experience proves that added to calomel it increases the antiphlogistic 
power of that medicine ; it may also be combined with tartar emetic, digi- 
talis, and colchicum, to the last of which it is an adjuvant of the greatest 
value. With calomel, solid opium or Dover's powders may be combined : 
with the other medicines, laudanum. I do not know that the sulphate of 
morphia possesses any advantages over these preparations. 

8. The influence of food, locomotion, speaking, and mental excitement, 
over the action of the heart is so great, that, in this disease, abstinence, 
rest, silence, and exclusion of society are indispensable. 

Thus far I have supposed the physician to have been called before valvu- 
lar or pericardial lesions, to any considerable extent, had taken place ; but 
in a majority of cases he will not have this advantage. If the case be endo- 
carditis, the lining membrane, especially that covering the valves, will not 
only be more or less softened and swelled, but deposits of lymph and fibrine 
will have commenced. These lesions, however, will not demand any modi- 
fication of the treatment. If the inflammation be pericardial, and has not 
been promptly met, the creaking sound which indicates slight roughening of 
the membrane, and incipient effusion of lymph, will not suggest any modi- 
fication of the treatment, but rather admonish the physician to great energy 
of antiphlogistic treatment. But if the dulness under percussion should be 
great in tone and extent, and the normal sounds of the heart are heard as 
from a depth, and there is no friction sound, copious effusion is indicated. In 
this stage of the disease venesection must be more sparingly employed, and 
greater reliance be placed on local bleeding, or blistering. The latter is 
especially beneficial, not only by producing revulsion, but exciting absorp- 
tion of the effused fluid. Even now, however, experience shows that a mild 
mercurial course is frequently of great value. In connection with, or following 
upon it, the infusion of digitalis, combined with spirit of nitrous ether, and 
diluted with any kind of diuretic tea, will be found useful by promoting 
absorption, while it subdues the remains of inflammation. To the same end, 



968 THE PRINCIPAL DISEASES, ETC. 

a course of hydriodate of potash, in five grain doses, three times a day, may 
be employed. Should the debility of the patient be great, and the signs of 
inflammation few and feeble, the iodide of iron is preferable ; to which the 
bark and other bitters may often be advantageously conjoined; especially 
when the inflammation has been rheumatic. When the pericardial accumu- 
lation is great, and absorption takes place slowly, the actual cautery applied 
to the precordial region, is regarded by many physicians as a valuable 
resource. I have not employed it. Throughout this treatment, it is of 
great importance to keep down the irritability of the heart, for which pur- 
pose opium or hyoscyamus may be used at night. To the narcotic given at 
this time it will be proper to add a sudorific, or, as combining both, to 
administer Dover's powder, and also to adopt other means, for restoring the 
functions of the skin. It is equally important to reproduce those of the 
liver, if they have been impaired, a condition not very likely to exist, how- 
ever, after the gentle mercurial course which such cases require. 

A diminution in the area and dulness of sound under percussion, will 
show the progress of absorption, which will be nearly completed when a 
friction sound is heard through the stethoscope. In many cases the effusion 
is not so great but that it is audible under a spontaneous absorption of the 
thinner parts of the lymph. Whenever it exists, the danger of adhesion of 
the pericardium is imminent. Under such circumstances, a complete subdual 
of the inflammation, and the promotion of rapid absorption, that the fibrine 
itself may be removed before it becomes organized, constitute all that art 
can suggest, and more than can generally be accomplished. 

If the effusion into the pericardium should have been blood or pus, the 
means enumerated will be most likely to promote its absorption ; but in both 
cases serious lesions will remain. The fibrine of the blood will, in all pro- 
bability, cause an adhesion of the pericardial walls ; and the same result 
will follow on the absorption of the pus, unless prevented by one still more 
serious, ulceration, for which nothing but a restorative treatment can be 
advised. 

Notwithstanding its adhesions, the pericardium is liable to renewed attacks 
of inflammation, which, however, are said not to be so violent as the first. 
If the adhesion is so general as to obliterate the sac, new effusions cannot 
of course occur; but when they are partial, the original condition may be 
reproduced, and the obliteration of the cavity completed. The consequences 
of this lesion, as well as that of the valves, will be discussed in the chapter 
on organic diseases of the heart. [Like so many more chapters, alas ! never 
written.] 

" Eheu fugaces ! Postume, Postume, 
Labuntur anni : nee pietas moram 
Rugis et instanti senectas 
Afferet, indomiteeque Morti." 

Hor. Lib. II. Carm. xiv. 



INDEX. 



Abdomen, 145. 

Abdominal organs, state of, in typhus 
fever, 489. 

symptoms of typhous fever, 403. 

typhous, 479. 
Abstinence, 707. 
Accidental causes of cardiac inflammation, 

960. 
Acetate of lead, 540. 

potash, 526. 
Acid, acetic, 527. 

citric, 527. 

malic, 527. 

nitric, 173. 

nitro-muriatic, 440. 

muriatic, 539. 

phosphoric, 539. 

tartaric, 527. 
Acids, mineral, 440. 

organic, vegetable, 527. 
Acido-saccharine fruits, 528. 
Action of contagion, 290. 

heart, irregular, 502. 
Acute bronchitis, 840. 

carditis, 947. 

laryngitis, 810. 
Adams, Fort, town of, 262. 
Adjuvants to quinine, 63. 
Administration of tartar emetic, mode of, 

521. 
Adulteration of calumbo, 541. 
Affection of spleen in inflammatory inter- 
mittent, 66. 

of stomach in inflammatory intermit- 
tent, 66. 

cri spinal cord, 499. 

of ganglionic system, 499. 

of liver, 67. 

of lungs, 67. 
Affections, organic, of heart, 705. 
Affusion, cold, 84, 605. 
Age of Galveston, 237. 

a cause of cardiac inflammations, 

965-8. 
Alcohol, 548. 
Alexandria, 245. 
Alterants in cardiac inflammation, 966. 

mercurial, 524. 
Altered constitution of blood in typhous 

fevers, 503. 
Alum, 440. 
Alvine discharges, 478. 



Ames, Dr., cases from, 125. 
Ammonia, 545. 

carbonate of, 536. 

muriate of, 337. 
Ammoniacal odor of blood, 438. 
Anaemia, 704. 

Annals of yellow fever, 201. 
Annual range of temperature, 445. 
Anasarcous infiltrations, 435. 
Anasarca from scarlatina, 608. 
Anatomy, pathologic, of Irish emigrant 
fever, 436. 

of intermittent fever, 138. 

of remittent, 142. 

of splenitis, 157. 

of yellow fever, 303. 

of typhous, 408, 486. 

of small-pox, 569. 

of measles, 43S, 588. 
Anatomical lesions in simple phlegmasia, 

686. 
Anatomico-physiological causes of phlo- 
gistic fevers, 665. 
Anatomico-physiological laws relative to 

the brain, 702. 
Antimony, tartarized, 535. 
Antiphlogistic treatment of phthisis, 941. 
Aorta, lining membrane of, 438. 
Apalachicola Bay, 235. 
Apalachian mountain region, 368. 
Apparatus, respiratory, 144, 479, 569. 
Appearances, post-mortem, 405. 
Applications to skin in yellow fever, 342. 

of blisters, 531. 

to throat in scarlatina, 606. 
Argenti nitras, 644. 
Arsenious acid, 65, 93. 
Arterial system, 502. 
Assafoetida, 545. 
Asthma, 825. 

hay, 825. 
Astringents, 539. 

metallic, 540. 

mineral, 540. 
Autumnal fever, 17. 

nomenclature of, 17. 

variety and identity of, 17. 

specific unity of, 18. 

geographical limits of, 18. 

places where unknown, 19. 

table of attacks of, at twenty-six 
military posts, 201. 

table of annual prevalence of, among 
British troops at Canada, 22. 



970 



INDEX. 



Autumnal fever, causes of, geographical 
limitation of, 23. 
influence of soil in limiting, 23. 
dead and decaying matter, 23. 
living vegetation, 24. 
surface water, 24. 
modus operandi of surface water in 

producing, 24. 
temperature, 26. 

table showing relation between tem- 
perature and, 27. 
modus operandi of temperature in 

producing, 29. 
speculations on efficient cause of, 30. 
meteoric hypothesis, 30. 
objections to this hypothesis, 31. 
malarial hypothesis, 33-6. 
vegeto-animalcular hypothesis, 37. 
arguments in favor of this hypothesis, 

38-41. 
value of these inquiries, 42. 
mode of action of remote cause of, 

43. 
first effects of remote cause, 43. 
application of the poison, 43. 
action on the skin, 43. 

in stomach and bowels, 43. 
in lungs, 44. 
in blood, 47. 
development of, 48-51. 
intermittents, 49. 

varieties and pathological causes 
of, 49. 
remittents, 49. 

varieties, 49. 
pathological character, 51. 
cold stage, 51. 

secretions affected, 51. 
derangement of liver, 52. 

of calorific functions, 52. 
general symptoms, 53. 
dangers of, 53. 
causes of death in, 53. 
hot stage, 54. 

causes of, 54. 

pathological conditions, 54. 
local affections, 55. 
pathology and consequences of, 136, 

150, 152, 153. 
mortality, 136. 
condition of blood in, 137. 
chronic action of cause of, 150. 
dyspepsia produced by, 151. 
subacute hepatitis produced by, 151. 
diseases of spleen produced by, 153. 



B. 



Balize, yellow fever at, 211. 
Bark in enlarged spleen, 165. 

in intermissions of fever, 89. 

time of exhibition, 89. 
quantity and intervals, 90. 
Basin, southern, typhous fever in, 368. 
Bath, nitro-muriatic, 69. 
Baton Rouge, 250. 

Bay of St. Louis, yellow fever at, 213. 
Biloxi, yellow fever at, 215. 
Pascagoula, yellow fever at, 215. 
Mobile, yellow fever at, 216. 
Pensacola, yellow fever at, 225. 



Bay of Apalachicola, yellow fever at, 235. 

Tampa, yellow fever at, 235. 
Bayou Sara, 253. 
Bed sores, 550. 
Belladonna in scarlatina, 601. 
Belmont, typhous fever at, 385. 
Bile in yellow fever, state of, 308. 
Bilious pneumonia, 868. 
Blacksburg, typhous fever at, 372. 
Black vomit, 317, 349. 
Black pepper, oil of, 93. 
Bladder, state of, in ship fever, 437. 

state of, in yellow fever, 309. 

gall, post-mortem appearance, 307. 
Blakely, yellow fever at, 225. 
Bleeding, local, 328, 529. 
Blisters, 531, 605, 645. 

directions for application of, 531. 

mode of dressing, 531. 
Blood, healthy, 682. 

condition of, in phlegmasia, 673. 

altered constitution of, 503. 

lesions of, 316, 503. 

action of malarial poison on, 43. 

condition of, in autumnal fever, 137. 
Bloodletting in yellow fever, 322. 

in intermittent fever, 58. 
Boleti in soil of the valley, 36. 
Borax, 606. 

Bourbon County, typhous fever at, 400. 
Bowel, perforation of, 551. 

affected in typhous, 478. 
by malarial poison, 43. 
Brady, Fort, 422. 

Brain, affected in inflammatory intermittent, 
68. 

post-mortem appearance in remittent 
fever, 144. 

state of, in Irish emigrant fever, 437. 

affected in typhous fever, 485. 

high warmth necessary to its action, 
538. 
British troops, autumnal fever among, 22. 
Bryce's test for vaccination, 576. 
Buffy coat of blood, 674. 
Buncombe County, typhous fever at, 373. 
Burnett's disinfecting fluid, 553. 
Butler, typhous fever at, 382. 



Calomel, in simple phlegmasia?, 693. 

'in yellow fever, 335. 
objections to, 335. 

in remittent fever, 99. 

in large doses, 102. 
Calorific function, state of, in continued 

fever, 480. 
Calumbo, 541. 

Camphor in final stage of typhous fever, 543. 
Camphor mixture, 544. 
Canadas, 426. 
Cantharides in nnal stage of typhous fever. 

543. 
Capillaries disturbed in typhous fever, 502. 
Carbonate of ammonia, 536. 

of lime, 540. 
Cardiac inflammations, 945. 

classification, 946. 

symptoms, 916. 

acute, 946. 



INDEX. 



971 



Cardiac inflammations, subacute, 947. 
causes of, 958. 

physiological, 958. 
age, 958. 
sex, 958. 

temperament, 958. 
muscular exertion, 959. 
constrained positions, 959. 
passions, 960. 
emotions, 960. 
accidental, 960. 
falls, 960. 
blows, 960. 
wounds, 960. 
pathological, 961. 
causes connected with blood, 964. 
sequelae, 964. 
treatment, 965. 
local bleeding, 966. 
blisters, 966. 
purging, 966. 
alterants, 966. 
saline sedatives, 966. 
narcotic sedatives, 966. 
Carditis, 915. 

symptoms, 915. 
effects, 956. 
causing gangrene, 958. 
Care of patient in final stage of typhous 

fever, 550. 
Carotids, pulsation of, 417. 
Carroll County, typhous fever in, 420. 
Carrot poultices, 551. 
Catarrh, 807. 

endemic, 807. 

symptoms of, 807. 
pathology of, 807. 
treatment of, 808. 
consequences, 808. 
epidemic, 809. 
exotic, 809. 

history, 809. 
symptoms, 810. 
consequences, 810. 
Catarrhus aestivus, 838. 
Cathartics in typhous fever, 522. 
in yellow fever, 331. 
in epidemic erysipelas, 641. 
Catheterism, 552. 
Causes of dropsy, 197. 

autumnal fever, 23. 
death in cold stage, 53. 
asthma, 834. 
Causes producing specific phlegmasia?, 667. 
wounds, 667. 
arsenic, 667. 
iodine, 667. 

corrosive sublimate, 667. 
cantharidin, 668. 
Central organs of innervation, phlegmasia? 

of, 722. 
Cerebritis, treatment of, 729. 
Cerebro-meningitis, prevention of, 725. 
culture of, 725. 
treatment of, 726. 
Cerebro-spinal meningitis, 751. 
epidemic, 751. 
history, 751. 
symptoms, 752. 
blood in, 755. 

pathological anatomy of, 755. 
brain, 755. 



Cerebro-spinal meningitis, path.anat.of,755. 
spinal cord, 756. 
abdominal organs, 756. 
modifying influences, 757. 
complications, 757. 
treatment, 761. 
Chalk mixture, 540. 
Chalk, mercury with, 540. 
Chalybeates in enlarged spleen, 166. 
Characteristic symptoms of Irish emigrant 

fever, 433. 
Chicken-pox, 584. 
Child-crowing, 826. 
Chloride of lime, 553. 

of zinc, 553. 
Cholagogues, 123. 

Christiansberg, epidemic typhous in, 372. 
Chronic action of cause of autumnal fever, 

150. • 

Chronic intermittent, 127. 
laryngitis, 815. 
bronchitis, 840. 
pleurisy, 876. 
encephalitis, 730. 
case of, 731. 
rheumatism, 778. 
treatment, 781. 
Chronology of pneumonia, 852. 
Circulation, lesions of, 501. 
City of Mobile, yellow fever in, 216. 
Classification of eruptive fevers, 564. 
phlegmasia?, 651. 
continued fevers, 464. 
Clergyman's sore throat, 815. 
history, 815. 
diagnosis, 815. 
Climate, modus operandi of, in producing 

phlogistic fevers, 657. 
Climate influences consumptive diathesis, 

884. 
Climatic causes of phlegmasia?, 787. 

relations, typhous fevers, 442. 
Ccecum, ulceration of, 492. 
Colchicum in simple phlegmasia?, 693. 
Cold stage of autumnal fever, 51. 
Cold affusion, 84, 528, 605. 
Collapse in intermittent fever, 94. 
Columbiana County, epidemic typhous in, 

384. 
Common phlegmasia?, 669. 
rise of, 669. 
establishment of, 669. 

causes of, 670. 
modes in which they arise, 671. 
condition of blood in, 673. 
fibrine, 673. 
buffy coat, 674. 
hyperinosis, 675. 
red corpuscles, 676. 
table of, 676. 
amount of, 676. 
reduction of, 677. 
cause of reduction, 677. 
constitutional irritation from re- 
duction of, 677. 
serum, 678. 
fatty matters, 678. 
extractive matters, 678. 
Comparison of yellow with autumnal fever, 

197. 
Comparative therapeutic effects of organic 
acids in typhous fever, 528. 



972 



INDEX. 



Complications of simple phlegmasia?, 701. 

scarlet fever, 600. 
Congestion of brain, 703. 
symptoms, 704. 
plethora, 704. 
anaemia, 704. 
prevalence of, 713. 
causes of, 713. 
Congestion, sanguineous, in typhous, 487. 

of spleen, 161. 
Connecticut, epidemic typhous in, 362. 
Connection of typhous with mean annual 

temperature, 442. 
Consumption, 884. 

statistics of, 884. 
etiology, 886. 

modus operandi of climate in pro- 
ducing, 890. 
pathological causes, 910. 
bronchial, 840. 

symptoms. 841. 
lesions, 842. 
cure, 842. 
pleuritic, 879. 
Constitution of blood altered in typhous 

fever, 503. 
Constitutional treatment of rheumatism, 

773. 
Constipation in continued fevers, 478. 
Contagious propagation of typhous fever, 

453. 
Cord, spinal, affection of, 499. 
Corn, hot ears of, applied to patient in 

typhous fever, 513. 
Cornine, sulphate of, 338. 
Corrosive sublimate, 644. 
Counter-irritation, 166. 
Counter-irritants, 407. 
Cow-pox, 572. 
Cow, vaccine infection from, 581. 

small-pox propagated to, without ino- 
culation, 582. 
Creasote, 541. 
Croup, 819. 

history, 819. 
diagnosis of, 819. 
pathology, 820. 
method^of cure, 823. 
secondary, 825. 
spasmodic, 826. 
Crucifera, remains of, in soil of the Valley, 

35. 
Cynanche trachealis, 819. 



D. 



Dallas County, typhous fever in, 418. 
Dangers of cold stage of autumnal fever, 53. 
Dead and decaying matter in soil of the 

Valley, 23. 
Death from autumnal fever, cause of, 53. 
Decoction of sassafras, poultices made with, 

551. 
Definition of yellow fever, 187. 
Deferred attacks of vernal intermittents, 
130. 
case of, 131. 
Delirium in Irish emigrant fever, 434. 
Deodorizing substances, 553. 
Depression, stage of, in yellow fever, 299. 



Derangement of liver in cold stage of inter 

mittent, 52. 
Development of malarial action, 48. 

typhous pneumonia, 873. 
Diagnosis of clergyman's sore throat, 815 

intermittent fever. 66. 

remittent fever, 95. 

perforation of bowel, 551. 

urticaria, 614. 

croup, 819. 

pneumonia, 854. 

congestion of brain, 715. 
Diarrhoea, precursory, in Irish emigrant 
fever, 434. 

bilious, 349. 

prevented by emetics, 521. 
Diathesis, dyspeptic, 948. 

chlorotic, 949. 

hysteric, 949. 

icteric, 949. 

menorrhagic, 950. 

plethoric, 950. 

utero-hemorrhagic, 950. 

tubercular. 884. 

typhous, 697. 
Diet in phlogistic fevers, 658. 
Difference between yellow and typhous 
fevers, 554. 

autumnal and typhous fevers, 556. 
Difficulties of treatment in typhous, 508. 
Digestive organs, morbid anatomy of, in 

small-pox, 570. 
Digitalis in simple phlegmasia?, 693. 
Diminished fibrine in typhous fever, 504. 

effects of, 505. 
Directions for bloodletting in typhous, 518. 
Diseases of spleen in autumnal fever, 153. 
Disinfecting substances, 553. 
Distinctive symptoms of typhous fever, 921. 
Disturbance of functions in intermittent 

fever, 74. 
Diuretics, 124, 165. 

Diversities of treatment in yellow fever, 322. 
Division of typhous fever by pathological 

anatomy, 469. 
Domestic influences predisposing to typhous 

fever, 450. 
Doses of calomel, excessive, 102. 

quinia in intermittent fever, 63. 
Douche, cold, 440. 

Dr. Ames, cases of remittent fever by, 125. 
Dress in phlogistic fevers, 660. 
Drinks in phlogistic fevers, 660. 
Dropsy, 174. 

history, 174. 

pathology, 175. 

causes, 175. 

supposed to be caused by enlarged 
spleen, 176. 

objections to this view, 176. 

caused by diseased liver, 177. 

facts in support of this, 177. 

depends on sanguineous vitiation, 
178. 

treatment, 179. 

sedative diuretics in, 180 

stimulant diuretics in, 180. 

diaphoretics, 181. 

excitation of absorbents, 181. 

digitalis, 181. 
Duodenum, lesions of, in yellow fever, 305. 
Dura matritis, diagnosis of, 718. 



INDEX. 



973 



Duration of forming stage of cerebral con- 
gestion, 717. 
Dyspepsia produced by autumnal fever, 151. 



Early distinctive symptoms of phthisis, 921. 
Ecchymosis of stomach, 490. 
Effects of diminished fibrine, 505. 

of carditis, 956. 
Effusions, serous, 487. 
Effusion of coagulable lymph on brain, 486. 

cold and tepid, 528. 
Emetic tartar, in pneumonia, 864-5. 
Emetics in scarlatina, 603. 

in typhous fever, 529. 
Emollient poultices, 551. 
Emotional causes of cardiac inflammations, 

960. 
Endemic catarrh, 807. 

symptoms of, 807. 
pathology of, 807. 
treatment of, 808. 
consequences of, 808. 
typhous fever, 453. 
Endocarditis, 953. 

symptoms of, 953. 
pathology of, 953. 
proximate lesions of, 964. 
Enlargement of pyloric glands, 490. 

mesenteric glands, 492. 
Epidemic typhous fever, 457, 561. 

local or spontaneous origin of, 457. 
Epidemic of measles in 1813, 593. 
catarrh, 809. 

history of, 809. 
consequences of, 810. 
of typhous fever, 385. 
at Belmont, 385. 
Greene County, 390. 
Lane Theological Seminary, 392 
Indiana, 399. 
Illinois, 399. 
Bourbon County, 400. 
Paris, 400. 
Scott County, 402. 
erysipelas, 638. 

bloodletting in, 639. 
emetics in, 640. 
cathartics in, 641. 
sudorifics in, 642. 
stimulants in, 643. 
tonics in, 643. 
argenti nitras in, 644. 
corrosive sublimate, 644. 
tincture of iodine, 645. 
blisters, 645. 
Epizootic small-pox, 581. 
Eruption of measles, 587. 
Eruptive typhous, 466. 
fevers, 563. 

specific origin of 564. 
classification of, 564. 
vesico-pustular, 564. 
variola, 564. 
vaccinia, 564. 
varioloid, 564. 
varicella, 564. 
exanthematous, 564. 
rubeola, 564. 
scarlatina, 564. 



Eruptive exanthematous fevers, 564. 
roseola, 564. 
urticaria, 564. 
erythematous, 564. 

erysipelas sporadica, 564. 
epidemica, 564. 
Erysipelas, 618. 

sporadic, 619. 

symptoms, 619. 

traumatic, 620. 

infantile, 620. 

phlegmonous, 620. 

cedematous, 621. 

causes of, 621. 

case of, alternating with diarrhoea, 

621. 
dangers of, 622. 
epidemic, 622. 

chronology, 622. 
geography, 622. 
contagion, 625. 
symptoms, 630. 
cold stage, 630. 
hot stage, 631. 
pathology, 637. 
Erysipelatous inflammation, 636. 

fever, 637. 
Establishment of common phlegmasia?, 669. 
Etiology of phlogistic fevers, 653. 
rheumatism, 764. 
yellow fever, 287. 
Eupatorium, infusion of, 513, 536. 
Evacuants in intermittent fever, 81. 
Excitement, mental, 711. 
Excited passions, 663. 
Exciting causes of splenitis, 158. 
Exclusion, cure of simple phlegmasia? by, 689. 
Excretions, functions of, 896. 
Exemption of Lake Erie coasts from typhous 

fever, 425. 
Exhaustive stage of yellow fever, 301. 
Exhibition of bark, 89. 
Exotic catarrh, 809. 
Expectorants, 407. 

Experiments with Burnett's fluid, 534. 
External stimulation, 117. 
emollients, 118. 
causes of phlogistic fevers, 615. 
Extract of belladonna in scarlatina, 601. 
Extractive matters of blood, 678. 



F. 



Facts showing that the remote cause of 
autumnal fever exerts itself upon stomach 
and bowels, 43. 
Facts supporting the theory that diseased 

liver causes dropsy, 177. 
Fatty matters of blood, 678. 
Faucium, scarlatina, 599. 
Fever, eruptive, of small-pox, 566. 
erysipelatous, 637. 
ictero-typhous, 554. 
intermittent, 56. 
simple, 56. 
history, 56. 
pathology, 56. 
symptoms, 57. 
treatment, 57. 

preparative, 58. 
bloodletting-, 58. 



974 



INDEX. 



Fever, intermittent, treatment, emetics, 58. 

cathartics, 59. 

curative, 60. 

sulph. quinine, 60. 

omission of preparatory, 62. 

continuance of, 64. 

vegetable bitters, 64. 

arsenious acid, 65. 
inflammatory, 66. 
diagnosis, 66. 
malignant, 71. 

general history, 72. 

symptomatology, 73. 

complications, 81. 

external stimulants, 83. 

heat, 83. 

cold affusion, 84. 

cases, 85. 

internal stimulants, 86. 

means of relieving the in- 
ternal organs, 86. 

treatment in the intermis- 
sion, 89. 

bark and sulphate of quinine, 
89. 

time of exhibition, 89. 

quantity and intervals of ex- 
hibition, 89. 

opium and sulphate of mor- 
phine, 92. 

arsenious acid, 93. 

piperine, 93. 

oil of black pepper, 93. 

calomel, 93. 

regimen, 93. 

relapses, 93. 

case, 94. 

conclusion, 94. 

collapse, 94. 
chronic and relapsing, 127. 

regular chronic recurrence, 
127. 

causes of protracted inter- 
mittents, 128. 

relapses, 129. 
vernal, 129. 

causes, 130. 

deferred attacks, 130. 

case, 131. 
treatment of winter cases, 131. 

of vernal cases, 133. 

by change of place, 134. 
salutary effects of chronic, 135. 
pathological anatomy of chronic, 
138. 
remittent, 95. 

simple and inflammatory, 95. 

symptoms, 95. 

diagnosis, 95. 

tendencies, 96. 

terminations, 96. 

treatment, 98. 

first treatment in the West, 98. 

Rush's powder, 99. 

opium in, 99. 

tartar emetic in, 99. 

calomel in, 99. 
advantages and disadvantages of 

this treatment, 100. 
treatment as for gastro-enteritis, 

101. 
the purging treatment, 101. 



Fever, remittent, calomel in excessive 
doses, 102. 
tendency at present time, 103. 
facts relative to quinine, 106. 
modifications of treatment, 111. 

from a northern climate, 111. 
southern climate, 111. 
malignant, 111. 

diagnosis, 112. 

pathology, 113. 

treatment, 116. 

indications for treatment, 
116. 

difficulties, 116. 

venesection and cupping, 
116. 

external stimulation, 117. 

external emollients, 118. 

vomiting, 119. 

lobelia inflata, 119. 

purging, 120. 

calomel, 122. 

refrigerants, 123. 

sedatives, 123. 

cholagogues, 123. 

diuretics, 124. 

sudorifics, 124. 

sulphate of quinine, 125. 

cases and remarks from Dr. 
Ames, 125. 

pathological anatomy of, 142. 

Stewardson's post-mortems, 
143. 

Powers, 147. 

Swett, 147. 
autumnal, 17. 

nomenclature of, 17. 
variety and identity of, 17. 
specific unity, 18. 
geographical limits, 18. 
places where unknown, 19. 
speculations on efficient cause, 

30. 
malarial hypothesis of, 33-6. 
vegeto-animalcular hypothesis, 

37. 
development of, 48. 
cold stage, 53. 

general symptoms, 53. 

dangers of, 53. 

causes of death in, 53. 
hot stage, 54. 

causes of, 54. 

pathological conditions, 54. 
local affections, 55. 
mortality, 136. 
condition of blood in, 137. 
dyspepsia produced by, 151. 
subacute hepatitis produced by, 

151. 
diseases of spleen produced by. 
153. 
Irish emigrant, 430. 

characteristic symptoms, 433. 
tongue, condition of, in, 434. 
delirium in, 434. 
precursory diarrhoea, 434. 
somnolency, 434. 
headache, 434. 
subsultus tendinum, 434. 
maculated skin, 435. 
petechias, 435. 



INDEX. 



975 



Fever, Irish emigrant, ecchymoses, 435. 
anasarcous infiltrations, 435. 
pathological anatomy, 436. 
brain, state of, 437. 
contents of thorax, 437. 
lungs, 438. 
heart, 438. 
lining membrane of aorta, 438. 
peritoneum, 438. 
ammoniacal odor of blood due to 
putrescency, 438. 
liver, spleen, gall-bladder, 
&c, 439. 
treatment, 439. 
cold douche, 440. 
stimulation, 440. 
mineral acids, 440. 
alum 440. 

nitro-muriatic acid, 440. 
mustard emetics, 440. 
typhous, 358. 

symptoms, 361. 

epidemics of, 361-8. 

treatment, 376, 384, 387, 401, 

406. 
abdominal symptoms, 403. 
state of circulation, 404. 
nervous system, 404. 
skin, 405. 
urinary secretions, 405. 
thoracic symptoms, 405. 
prognosis, 405. 

post-mortem appearances, 405. 
expectorant treatment, 407. 
local histories, 410-29. 
etiologic generalizations, 441. 
climatic relations, 442. 
seasonal relations, 444. 
influence of annual range of tem- 
perature, 445. 
hygrometric relations, 446. 
topographical relations, 447. 
physiological influences, 449. 
sporadic, 452. 
primary, 452. 
secondary, 452. 
contagious propagation, 453. 
endemic, 453. 
contagion in Europe, 453. 
epidemic, 457. 
classification of, 464. 
eruptive and non-eruptive, 466. 
maculated and unmaculated, 466. 
nervous and putrid, 466. 
division according to pathological 

anatomy, 469. 
period of incubation, 472. 
stage of development, 473. 
excitement, 474. 
yellow, 187. 

nomenclature, 187. 
definition, 187. 
geography of, 188. 
chronology of, 189. 
local histories, 191, 286. 
etiological deductions, 287. 
facts against contagiousness of, 

288. 
does not conform to laws of con- 
tagious fever, 289. 
hypothesis of contagious fermen- 
tation, 291. 



Fever, yellow, calomel in, 335. 
objections to, 335. 
non-purgative alkaline salts, 336. 

formula for, 337. 
muriate of ammonia in the third 
1 stage of, 337. 
applications to the skin, 342. 
irritants, 342. 
sudorifics, 343. 
remedies in third stage, 343. 
general directions, 344. 
positive treatment, 345. 
eruptive, 563. 

specific origin, 564. 
classification, 564. 
vesico-pustular, 564. 
exanthematous, 564. 
erythematous, 564. 
phlogistic, 653. 

etiology of, 653. 
predisposing causes, 653. 
modifying causes, 653. 
temperament, 653. 
age, 654. 
sex, 655. 
climate, 656. 

modus operandi. 657. 
diet, 658. 
drinks, 660. 
dress, 660. 
occupations, 661. 
casualties, 661. 
mental exercise, 663. 
excited passion, 663. 
pathological causes, 664. 
difference between yellow and 
typhous, 554. 
Fibrine in common phlegmasia?, 673. 

origin of, in healthy blood, 682. 
Flame inhaled, producing disease, 805. 
Functional lesions of the liver, 168. 
Fungi, remains of, in soil of the Valley, 36. 
Fuzz-cotton, a cause of inflammation, 799. 



G. 



Gall-bladder, pathological anatomy of, in 

yellow fever, 307. 
Gallipolis, yellow fever at, 285. 
Galveston, yellow fever at, 236. 
Ganglions of great sympathetic, 312. 
Gargles in scarlatina, 606. 
Gaseous impurities causing pulmonary in- 
flammation, 805. 
Gastric repletion a cause of congestion of 

brain, 707. 
General symptoms in cold stage of autum- 
nal fever, 53. 
General typhous epidemic constitution, 361. 
Genito-urinary apparatus, lesion of, in 
typhous fever, 492. 
organs, pathology of, in small-pox, 
370. 
Gentian in typhous fever, 541. 
Geographical limits of measles, 586. 
epidemic erysipelas, 622. 
pneumonia, 852. 
autumnal fever, 18. 

causes of, 23. 
causes of respiratory phlegmasia?, 



978 



INDEX. 



Glandular suppurations, 551. 
Graminea, remains of, in soil of Valley, 35. 
Green County, typhous fever at, 390. 
Guaiacum, tincture of, in typhous fevers, 
544. 



H. 



Hay asthma, 825, 838. 

history and causes, 834. 

symptoms, 836. 

palliatives, 837. 

pathology, 836. 
Headache in Irish emigrant fever, 434. 
Healthy blood, origin of fibrine in, 682. 
Heart, softening of, in typhous fever, 489. 

organic affections of, 705. 

pathological anatomy of, in yellow 
fever, 310. 
Heart's action, irregularity of, 502. 
Pleat applied in intermittent fever, 83. 

solar, 708. 
Hectic stage of phthisis, 933. 
Hemorrhages, 540. 
Hemorrhagic phenomena of typhous, 481. 

yellow fever, 317. 
Hepatic disorder in phthisis, 925. 

typhous fever, 479. 
Hepatization of lung in phthisis, 925. 
Hereditary transmission of tubercular dia- 
thesis, 908. 
History of epidemic catarrh, 809. 

cerebro-spinal meningitis, 751. 

acute laryngitis, 810. 

clergymen's sore throat, 815. 

dropsy, 174. 

scarlet fever, 594. 
Hornet, yellow fever aboard the, 231. 
Hot stage of autumnal fever, 54. 
Hudson, Port, yellow fever at, 251. 
Hydrargyrum cum creta, 540. 
Hydrocephalus, 735. 

Hy drographical causes of respiratory phleg- 
masia?, 789. 
Hygienic rules for tubercular diathesis, 908. 

means of treatment in typhous fever, 
512. 

management in stage of excitement, 
516. 
Hyperinosis, 675. 
Hypertrophy of spleen, 161. 
Hypothesis, meteoric, of autumnal fever, 30. 

malarial, of autumnal fever, 33-6. 

vegeto-animalcular of autumnal fever, 
37. 
Hysteric diathesis, 949. 



I. 



Iberia, New, yellow fever at, 241. 

Icteric diathesis, 949. 

Identities of yellow and typhous fevers, 554. 

Illinois, typhous fever in, 399. 

Impoverished state of blood in yellow fever, 
347. 

Impure air a necessary condition to the ac- 
tion of contagion, 290. 

Inaction of the liver, 169. 

Incubative period of typhous fevers, 472. 

Indiana, typhous fever in, 399. 



Indications for emetics, 519. 
Infantile erysipelas, 620. 
Infection, variolous, 5S4. 
Inflammation, erysipelatous, 636. 
of organs of motion, 764. 
of organs of special sense, 764. 
Inflammations of respiratory organs, 807. 
cardiac, 945. 

classification, 946. 
symptoms, 946. 
acute, 947. 
subacute, 947. 
of brain, secondary, 722. 
of spleen, 157. 

symptoms, 157. 
morbid anatomy, 157. 
treatment, 158. 
subacute, 159. 
parenchymatous, 159. 
Inflammatory stage of phthisis, 931. 

remittent fever, 95. 
Influences modifying yellow fever, 303. 

salubrious, ascribed to surface-water, 
26. 
Influenza, 809. 
Infusion of serpentaria, 536. 
Innervation, phlegmasia? of central organs 

of, 702. 
Intermittent fever, 56. 
simple, 56. 

history of, 56. 
pathology, 56. 
symptoms, 57. 
treatment, 57. 

preparations, 58. 
bloodletting, 58. 
emetics, 58. 
cathartics, 59. 
curative treatment, 60. 
sulphate of quinine, 60. 
effects of, 61. 

contraindications for its use, 61. 
omission of preparatory treat- 
ment, 62. 
times of administering quinine. 

62. 
doses, 63. 

required amount, 63. 
adjuvants, 63. 

continuance of treatment, 64. 
vegetable bitters, 64. 
arsenious acid, 65. 
inflammatory, 66. 
diagnosis, 66. 
pathology, 66. 
treatment, 68. 
malignant, 71. 

general history, 72. 
symptomatology, 73. 
cases, 78. 
pathology, '80. 
complications, 81. 
treatment in paroxysm, 81. 
evacuants, 81. 
bloodletting, 81. 
emetics, 82. 
cathartics, 82. 
Introduction to eruptive fevers, 563. 
Irish emigrant fever, 430. 

characteristic symptoms, 433. 
tongue, condition of, 434. 
delirium in, 434. 






INDEX. 



977 



Irish emigrant fever, precursory diarrhoea 
434. 

somnolency in, 434. 

headache, 434. . 

subsuitus tendinum, 434. 

maculated skin, 435. 

petechias, 435. 

ecchymosis, 435. 

anasarcous infiltrations, 435. 

pathological anatomy, 436. 

brain, state of, 437. 

contents of thorax, 437. 

lungs, 438. 

heart, 438. 

lining membrane of aorta, 438. 

peritoneum, 438. 

ammoniacal odor of blood in, 438. 

liver, spleen, gall-bladder, &c, 439. 

treatment, 439. 

cold douche, 440. 

stimulation, 440. 

mineral acids, 440. 

alum, 440. 

nitro-muriatic acid, 440. 

mustard emetics, 440. 
Irritants, in yellow fever, 342. 
Irritation, spinal, 926. 

myelitic, 747. 

treatment, 749. 
Iritis, 784. 



Jackson, exemption of, from yellow fever. 

213. 
Joseph's, St., yellow fever at, 235. 



K. 



Kentucky, typhous fever in, 400. 
Kidney, pathological anatomy of, in yellow 
fever, 309. 



L. 



Laryngitis, acute, 810. 

history, 810. 

symptoms, 810. 

treatment, 811. ' 

exudative, 812. 

membranous, 812. 

oedematous, 812. 

suppurative, 814. 

secondary, 814. 

chronic, 815. 
Legislative enactments concerning vaccina- 
tion, 573. 
Leguminosae, remains of,in soil of theVallev, 

35. 
Lesions of pericarditis, 964. 

endocarditis, 964. 

muscular substance, 965. 

pneumonia, 854. 

bronchial consumption, 842. 

blood, 316, 503. 

special, of yellow fever, 304. 

anatomical, of simple phlegmasiae, 
686. 
Lichen, 612. 

tropicus, 612. 
vol. n. 62 



| Lining membrane of aorta, state of, in Irish 
emigrant fever, 438. 
Liver affected in inflammatory intermit- 
tents, 67. 
Irish emigrant fever, 439. 
yellow fever, 306. 
diseases of, from autumnal fever, 168. 
functional lesions, 168. 
inaction or torpidity of, 169. 
subacute inflammation of, 170. 

a result of autumnal fever, 170. 
symptoms, 172. 
treatment, 173. 
nitric acid, 173. 
ext. taraxaci, 173. 
sulphur waters, 173. 
Lobelia inflata, 119. 
Local histories of typhous fevers, 368. 
origin of typhous fever, 462. 
history of yellow fever, 191. 
bleeding in cardiac inflammations, 
966. 
yellow fever, 328. 
Lower town of Bayou Sara, yellow fever at, 

255. 
Lungs, state of, in Irish emigrant fever, 438. 



M. 



Maculated skin of Irish emigrant fever, 435. 

typhous, 466. 
Maine, typhous epidemic in, 363. 
Malarial hypotheses of autumnal fever, 
33-6. 

pneumonia, 869. 
Malic acid, 527. 
Malignant remittent fever, 111. 

intermittent fever, 71. 
Management of vaccination, 575. 
Mania a potu, 721. 

Material causes of phlogistic fever, 665. 
Maury County, typhous epidemic in, 413. 
Means for relieving internal organs in inter- 
mittent fever, 86. 

of cure in simple phlegmasiae, 688. 
Measles, 586. 

geography, 586. 

chronology, 586. 

subjects, 586. 

propagation, 586. 

symptoms, 586. 

eruption, 587. 

pathological anatomy, 588. 

treatment, 589. 

epidemic of, in 1813, 593. 
Medfield, typhous epidemic at, 361. 
Medical topography of Belmont County, 

373. 
Memphis, yellow fever at, 283. 
Meningitis, epidemic cerebro-spinal, 751. 

history, 751. 

symptoms, 752. 

pathological anatomy, 755. 
blood, 755. 
brain, 755. 
spinal cord, 756. 
abdominal organs, 756. 

modifying influences and complica- 
tions, 757. 

pathological speculations, 760. 

modes of treatment, 761. 



978 



INDEX. 



Mental exercise, 663. 

excitement producing congestion of 
brain, 711. 
Mercurial cathartics, 524. 

alteratives, 524. 
Mesenteric ganglia affected in yellow fever, 

309. 
Metallic astringents, 540. 
Meteoric hypotheses of autumnal fever, 30. 
Method of cure in croup, 823. 
Michigan, typhous epidemic in, 425. 
Milwaukie, typhous epidemic in, 424. 
Mineral astringents, 540. 

acids, 440. 
Miscellaneous causes of pulmonary inflam- 
mation. 799. 

cotton fuzz, 799. 

mineral impurities, 804. 

gaseous impurities, 805, 

Same inhaled, 805. 

mechanical violence, 805. 

pathological causes, 807. 
Modes in which common phlegmasiae arise, 

671. 
Modified small-pox, 579. 

relations to variola, 579. 
vaccinia, 579. 

symptoms, 580. 

treatment, 581. 
Modifying causes of phlogistic fevers. 653. 
Mod us operandi of temperature in producing 

autumnal fevers, 29. 
Montreal, typhous fever at, 427. 
Mortality in vaccinated cases, 574. 

from yellow fever, 351. 
Mucous inflammations of respiratory organs, 

807. 
Muriatic acid, 539. 

Muriate of ammonia in yellow fever, 337. 
Muscles of animal life, 313. 
Muscular exertion, a cause of cardiac in- 
flammations, 959. 
Mustard emetics, 440. 
Myelitic irritation, 747. 

treatment, 749. 



N 



Narcotic sedatives, 966. 
Natchez, yellow fever in, 262. 
Natchitoches, yellow fever in, 245. 
Nature of soil in Valley, 33. 
Nausea in typhous fever, 478. 
Nervous fever, 466. 

system, state of, in typhous, 404. 
Neuralgia, periodical, 182. 
seats, 183. 
symptoms, 183. 
pathology, 184. 
treatment, 185. 
New York, epidemic typhous in, 369. 
Mexico, epidemic" typhous in, 421. 
Orleans, yellow fever in, 192. 
Design, yellow fever in, 285. 
Iberia, yellow fever in, 241. 
Nitrate of lead, 553. 
Nitric acid, 173. 

preferred for hepatic disorders, 538. 
Nirro-muriatic acid, 440. 
Nomenclature of autumnal fever, 17. 
yellow fever, 187. 



Non-purgative alkaline salts, 356. 

North Alabama, typhous epidemic in, 412. 

Northern climate, treatment modified by, 

111. 
Notice, historical, of scarlet fever, 574. 
Numerical method of Louis, objection to, 

533. 



Oak forests, exuviae of, 35. 
Objections to meteoric hypothesis of autum- 
nal fever, 31. 
specifics, 432. 

numerical methods of Louis, 533. 
tartar emetic, 532. 
calomel in yellow fever, 335. 
inoculation, 574. 
Observationsin yellow fever by a Gulf com- 
mander, 215. 
Obstacles to cicatrization, 940. 
Obstinate perseverance of typhous fever, 

510. 
GCdematous laryngitis, 812. 
Ohio, typhous epidemic in, 365. 
Oil of black pepper, 93. 
Oldham County, typhous epidemic in, 407. 
Oleum terebinihinae in typhous fevers, 543. 
Ontario, typhous fever ai, 425. 
Opelousas, yellow fever at, 242. 
Ophthalmitis, 782. 
Opiates in typhous fever, 407. 
Opium in remittent fever, 9 C J. 
Organic affections of heart, 705. 
acids in typhous fever, 527. 
matter of soil of Valley 34: 
vegetable acid, 527. 
Organs, respiratory, mucous inflammations. 
807. 
of innervation, phlegmasia? of, 722. 
of motion, inflammation of, 764. 
most affected in typhous fever, 485. 
brain, 485. 
bowels, 485. 
lungs, 486. 
spleen, 486. 
Origin of contagion, 412. 

fibrine in healthy blood, 682. 
scarlatina, 595. 



Palliative treatment of asthma, 837. 
Parisburg, typhous fever at, 370. 
Pascagoula Bay, yellow fever at, 213. 
Pathological anatomy of Irish emigrant 
•fever, 436. 
intermittent fever, 56. 
small-pox, 569. 
yellow fever, 353. 
causes of cardiac inflammation, 961. 
Pensacola Bay, yellow fever at, 225. 
Pepper, black, oil of>93. 
Perforation of the bowel, 551. 
Periodical neuralgia, 182. 
seats of, 183. 
symptoms, 183. 
pathology, 184. 
treatment, 185„ 



INDEX. 



979 



Peritoneum, state of, in Irish emigrant fever, 
438. 
yellow fever, 310. 
Pertussis, 825. 

Petechiae in Irish emigrant fever, 435. 
Phlegmasia?, 647. 

classification, 651. 
table of, 652. 
specific. 667. 

causes producing, 667. 
wounds, 667. 
arsenic, iodine, corrosivesub- 

limate, 667. 
pungent, acrid, and narcotico- 
acrid vegetable poisons, 
667. 
cantharidin, 668. 
common, 669. 

rise and establishment of, 669. 
causes of, 670. 

modes in which they arise, 671. 
condition of blood in, 673. 

fibrine, 673. 
buffy coat, 674. 
hyperinosis, 675. 
red corpuscles, 676. 

table of amount of, 676. 
reduction of, 677. 
cause of reduction, 677. 
serum, 678. 
fatty matters, 678. 
extractive matters, 678. 
simple, 684. 

proofs of, 684. 
terminations, 684. 
anatomical lesions, 686. 
indications of cure, 688. 
means of cure, 688. 
by exclusion, 689. 
abstraction, 689. 
bloodletting, 689. 
purging, 690. 
refrigerants, 691. 
changing mode of action, 692. 
tartarized antimony, 692. 
calomel, 693. 
digitalis, 693. 
squill, 693. 
colchicum, 693. 
allay irritability, 694. 
equalize excitement, 695. 
promote secretion, 697. 
repair waste, 699. 
resiore strength of the tissues, 

699. 
pathological complications, 701. 
of central organs of innervation, 702. 
pathology, 722. 
pathological lesions, 724. 
prevention of cerebro-meningitis, 

725. 
cure of, 725. 
treatment of, 726. 
of respiratory organs, 787. 
etiology, 787. 
climatic causes, 787. 
geographical, 788. 
hydrographical, 789-99. 
Phlogistic fevers, 653. 
etiology of, 653. 
predisposing causes, 653. 
modifying causes, 653. 



Phlogistic fevers, temperament, 65?. 

age, 654. 

sex, 655. 

climate, 656. 

modus operandi of, 657. 

diet, 658. 

drinks, 660. 

dress, 660. 

occupations, 661. 

casualties, 661. 

mental exercise, 663. 

excited passion, 663. 

pathological causes, 664, 

moditying causes, 665. 

external or material, 665. 

anatomico-physiological, 665. 

pathological, 666. 
Phthisis pulmonalis, 921. 

early distinctive symptoms, 921. 

congestion of pharynx, 923. 

chronic laryngitis, 924. 

tracheal ulceration, 924. 

chronic bronchitis, 924. 

hepatization of lung, 925. 

chronic pleurisy, 925. 

spasmodic asthma, 925. 

affections of heart, 926. 

spinal irritation, 926. 

dyspepsia, 927. 

hepatic disorders, 927. 

chlorosis, 928. 

intermittent fever, 928. 

pathology, 929. 

progress, 929. 

stage of non-inflammatory deposition, 
929. 

inflammatory stage, 931. 

hectie stage, 933. 

treatment, 937. 

before tho rise of inflammation 

and fever, 937. 
of phlegmasial stage, 939. 
of suppurating stage, 940. 
obstacles to cicatrization, 941. 

antiphlogistic treatment, 941. 

tonic treatment, 941. 

miscellaneous remedies, 943. 
Physiological causes of cardiac inflamma- 
tions, 958. 
Piperine, 93. 

Pittsburg, typhous fever at, 382. 
Plaquemines, yellow fever at, 248. 
Pleura, state of, in yellow fever, 310. 
Pleurisy, acute, 874. 

diagnosis of, 874. 
symptoms, 874. 
physical lesions, 874. 
treatment, 875. 

chronic, 876. 
Pleuritic consumption, 879. 
Pneumonia, 852. 

geography, 852. 

chronology, 852. 

subjects, 852. 

diagnosis, 852. 

lesions, 852. 

symptoms, 854. 

physical signs, 855. 

treatment, 860. 

tartar emetic, 864-5. 

typhoid, 866. 

symptoms, 867. 



980 



INDEX, 



Pneumonia, bilious, 868. 

malarial, 869. 

diagnosis, 869. 
treatment, 871. 
Popular objections to vaccination, 573. 

empiricism, 135. 
Population of New Orleans, 195. 
Port Hudson, yellow fever at, 251. 
Potassa, nitrate of, in scarlatina, 606. 
Precursory diarrhoea in Irish emigrant 

fever, 434. 
Prejudices against cold affusion, 529-30. 
Preparative treatment in intermittent fever, 

50. 
Primary typhous fever, 452. 
Progress of eruption in small-pox, 567-8. 
Prophylactic value of vaccination, 572. 
Proposed legislative enactments concerning 

it, 573. 
Proximate lesions of pericarditis, 964. 

endocarditis, 964. 
Pulmonary inflammation, causes of, 799. 

cotton-fuzz, 799. 

mineral impurities, 804. 

gaseous impurities, 805. 

flame inhaled, 805. 

mechanical violence, 805. 

pathological causes, 807. 
Purgative pill, 536. 

Purging treatment in remittent fever, 101. 
Putrescency of blood causing ammoniacal 

odor, 338. 
Putrid fever, 466. 



Quebec, typhous fever at, 429. 



R. 



Red corpuscles, 676. 

table of amount of, 676. 
reduction of, 677. 

constitutional irritation from, 677. 
Refrigerants in simple phlegmasiae, 691. 
Regimen for intermittent fever, 91. 
Relations between climate and consumptive 

diathesis, 884. 
Remains of graminea and equisetacea, 35.- 

of fungi and boleti, 35. 
Remittent fever, 95. 

simple and inflammatory, 95. 
symptoms, 95. 
diagnosis, 95. 
tendencies, 96. 
terminations, 96. 
treatment, 98. 

first treatment in the West, 98. 
Rush's powder, 99. 
tartar emetic in, 99. 
calomel in, 99. 
advantages and disadvantages of this 

treatment, 100. 
treatment as for gastro-enteritis, 101. 
the purging treatment, 101. 
calomel in excessive doses, 102. 
tendency at present time, 103. 
facts relative to quinine, 106. 
modifications of treatment, 111. 
from a northern climate, 111. 



Remittent fever, southern climate, 111. 
malignant, 111. 
diagnosis, 112. 
pathology, 113. 
treatment, 116. 
indications for, 116. 
difficulties, 116. 
venesection and cupping, 116. 
external stimulation, 117. 

emollients, 118. 
vomiting, 119. 
lobelia inflata, 119. 
purging, 120. 
calomel, 122. 
refrigerants, 123. 
sedatives, 123. 
cholagogues, 123. 
diuretics, 124. 
sudorifics. 124. 
sulphate of quinia, 125. 
pathological anatomy of, 142. 
post-mortem revelations, 143. 
brain, 144. 

respiratory apparatus, 144. 
pleura and lungs, 144. 
circulatory organs, 145. 
heart, 145. 
abdomen, 145. 
liver, 145. 
Stewardson's post-mortems, 

143-8. 
Powers's post-mortems, 147. 
Swett's post-mortems, 147. 
Remitto-typhous fever, 557. 
Remote causes of urticaria, 615. 
Resinous matter of soil of Valley, 35. 
Respiratory apparatus, 144. 
Rheumatism, 764. 

relations with myelitis, 764. 
etiology of, 765. 
pathology, 768. 
anatomical lesions, 771. 
case, 772. 
acute, 773. 

constitutional treatment of, 773. 
topical remedies, 777. 
Rise and spread of typhous fever, 393. 
Rise of common phlegmasiae, 669. 
Rodney, yellow fever at, 277. 
Roseola, 612. 
Rose-rash, 612. 
Rubeola, 586. 

geography, 586. 
subjects, 586. 
chronology, 586. 
propagation, 586. 
symptoms, 586. 
eruption, 587. 
pathology, 588. 
treatment, 589. 
epidemic of, in 1813, 593. 



Salubrious influence ascribed to surface- 
water, 26. 
Scarlatina, 594. 

historical notice, 594. 

origin and progress, 595. 

seasons, 596. 

subjects, 596. 






INDEX. 



981 



Scarlatina, varieties, 596. 
symptoms. 596. 
simplex, 596. 
anginosa, 597. 
maligna, 598. 
faucium, 599. 
prognosis, 599. 
complications, 600. 
consequences, 600. 
morbid appearances, 600. 
prevention, 601. 
extract belladonna, 601. 
treatment, 602. 
bloodletting, 603. 
emetics, 603. 
purging, 604. 
calomel, 604. 
cold affusion, 605. 
blisters, 605. 

applications to throat, 606-7. 
gargles, 606. 
chloride of soda, 606. 

lime, 606. 
potassa, nitrate of, 606. 
borax, 607. 
tonics, 607. 
anasarca, 608. 

treatment, 608. 
Sclerotitis, 783. 
Simple remittent fever, 95. 

intermittent fever, 56. 
Small-pox, 564. 

modified, 564. 

relations to variola, 579. 
vaccinia, 579. 

symptoms, 580. 

treatment, 581. 
prevalence of, 565. 
etiology, 565. 
symptoms, 566. 
eruptive fever of, 566. 
eruption, 567. 
pathological anatomy, 569. 

nervous centres, 569. 
envelopes, 569. 

organs of respiration, 569. 
circulation, 569. 
digestion, 570. 
treatment, 570. 
Soil of the Valley, nature of, 33. 
organic matter of, 34. 
resinous matter of, 35. 
Somnolency in Irish emigrant fever, 434. 
Specific origin of eruptive fevers, 564. 
Spleen, suppuration of, 159. 

cases, 159-60. 
hypertrophy of, 161. 
congestion, 161. 
enlargement of, 161. 

duration, 162. 

cases, 162-3. 

how detected, 163. 

treatment, 164. 

emetics, 164. 

cathartics, 164. 

diuretics, 165. 

bark, 165. 

iodine, 165. 

chalybeates, 166. 

counter-irritation, 166. 

change of place, 166. 
Splenitis, 157. 



Splenitis, symptoms of, 157. 

morbid anatomy of, 157. 

treatment of, 158. 

subacute, 159. 

parenchymatous, 159. 
Sporadic complications of typhous fever, 
561. 

erysipelas, 564. 
Stages of yellow fever, 298. 
Stewardson's post-mortems, 143-8. 
Stimulation in Irish emigrant fever, 440. 
Stimulants, external, 83. 
Subsultus tendinum, 434. 
Sudorifics in remittent fever, 124. 
Sulphate of quinia, 125-137. 

effects of, 61. 

contra-indications for its use, 61. 
Suspended secretions, 348. 
Sympathetic, great, ganglions of, 312. 
Symptoms of yellow fever, 298. 

intermittent fever, 57. 

remittent fever, 95. 
Swett's post-mortems, 147. 



T. 



Tartarized antimony, 692. 
Temperature, modus operandi of, in pro- 
duction of autumnal fever, 29. 
Tincture of iodine, 645. 
Tonics in erysipelas, 643. 
Topical remedies in rheumatism, 777. 
Tracheal ulceration, 924. 
Treatment of pneumonia, 860. 
Tubercular pneumonitis, 883. _ 
diathesis, 884. 
encephalitis, 735. 
Typhous fever, 358. 

introduction to, 358. 
epidemic of, in Massachusetts, 361. 
Connecticut, 362. 
Vermont, 363. 
Maine, 363. 
New York, 364. 
Ohio, 365. 
Keniucky, 366. 
New Orleans, 367. 
local histories, 368. 
Southern basin; Appalachian 
mountain regions, 368. 
sub-epidemic and sporadic visitations, 
368. 
Elliottsville, 369. 
Parisburg, 370. 
Blacksburg, 372. 
Christiansburg, 372. 
Buncombe County, 373. 
medical topography, 373. 
history, 374. 
symptoms, 376. 
sub-alpine parts of Tennessee, 377. 
history, 377. 
treatment, 378. 
Uniontown, 378. 
Washington, 380. 
Wellsburg, 381. 
Pittsburg, 382. 
Butler, 382. 
Trumbull, 383. 
Columbiana County, 384. 
Belmont County, 385. 



982 



INDEX. 



Typhous fever, Belmont County, history, 
385. 
symptoms, 386. 
treatment, 387. 
Greene County, 390. 
Lane Theological Seminary, 392. 
Indiana, 399. 
Illinois, 399. 
Kentucky, 400. 

Bourbon County, 400. 
Paris, 400. 

history, 400. 
symptoms, 401. 
treatment, 401. 
Scott County, 402. 
symptoms. 403. 
progress, 403. 
abdominal symptoms, 403. 
state of circulation, 404. 
nervous system, 404. 
skin, 405. 
urinary secretion, 405. 
thoracic symptoms, 405. 
prognosis, 405. 

post-mortem appearances, 405'. 
treatment, 406. 
venesection, 406. 
emetics, 406. 
purgatives, 406. 
sudorifics, 406. 
counter-irritants, 407. 
expectorants, 407. 
opiates, 407. 

expectant treatment, 407. 
at Oldham County, 407. 
history of, 407. 
symptoms of, 407. 
pathological anatomy, 408. 
treatment, 408. 
Smith County, 410. 

cases, 410. 
North Alabama, 412. 
Maury County, 413. 
treatment, 414. 
South Alabama, 415. 

Benton County, 415. 
symptoms, 415. 
post-mortem appearances, 

416. 
intense pulsation of carotids, 
417. 
Dallas County, 418. 
Carroll County, 420. 
history, 420. 
symptoms, 420. 
treatment, 420. 
New Mexico, 421. 
Fort Brady, 422. 
Milwaukie, 424. 
Michigan, 425. 
exemption of Lake Erie coasts, 
425. 
southern basin of Lake Ontario, 

425. 
Canadas, 426. 
Montreal, 429. 
Trois Rivieres, 429. 
etiological generalizations, 441. 
climatic relations, 442. 
connection with mean annual tem- 
perature, 442. 
seasonal relations, 444. 



Typhous fever, influence of annual range 
of temperoture ; 445. 
hygrometric relations, 44<>. 
topographical relations, 447. 
physiological influences, 449. 
domestic and social influences, 450. 
in badly ventilated houses, 450. 
common among the poor, 450. 
from poor nourishment, 451. 
sporadic, 452. 
primary, 452. 
secondary, 452. 
contagious propagation, 453. 
endemic, 453. 
epidemic, 457. 
classification, 464. 
synochus and typhous, 465. 
eruptive and non eruptive, 466. 
maculated and unmaculated, 466. 
nervous and putrid, 466. 
symptoms, 472. 
period of incubation, 472. 
stage of development, 473. 

excitement, 474. 
symptoms in digestive system, 477. 
furred tongue, 478. 
red and dry pharynx, 478. 
gastric symptoms, 478. 
nausea, 478. 
constipation, 478. 
diarrhoea, 478. 
alvine discharges, 478. 
peritoneal tenderness, 479. 
gurgling in right iliac region, 

479. 
abdominal typhous, 479. 
hepatic derangement, 479. 
splenitis, 479. 
respiratory apparatus, 479. 
state of calorific function, 480. 
hemorrhagic phenomena, 481. 
vibices, 482. 
sudamina, 483. 
progress, 483. , 
termination of, 483. 
organs most affected, 485. 
pathological anatomy, 486. 
sanguineous congestion, 487. 
serous effusions, 487. 
inflammatory origin, 495. 
typhous diathesis, 497. 
morbid innervation, 498. 
affection of spinal cord, 499. 
ganglionic system, 499. 
disordered muscular motion, 499. 
subsultus tendinum, 500. 
morbid sensation, 500. 
lesion of circulation, 501. 
irregularity of heart's action, 502. 
disturbed capillaries, 502. 
arterial system, 502. 
lesion of blood, 503. 
altered constitution of, 503. 
diminished fibrine, 504. 

effects of this diminution, 505. 
treatment, 508. 
difficulties of, 508. 
uncertainties of, 508. 
failures of, 508. 
different treatment, 509. 
cannot be arrested by treatment 
509. 



INDEX. 



983 



Typhous fever, obstinate perseverance and 
causes, 510. 
treatment in forming stage, 511. 
hygienic means, 512. 
emetic, 512. 
warm bath, 512. 
sudorifics, 512. 
eupatorium perforatum, 513. 
Dover's powder, 513. 
morphia sulphatis, 513. 
surrounding the patient with hot ears 

of Indian corn, 513. 
treatment of early part of stage of 

excitement, 516. 
hygienic management, 516. 
general bloodletting, 518. 

directions for, 518. 

topical bleeding, 519. 

emeiics, 519. 

indications for, 519. 

contraindications for, 519, 

emetics prevent diarrhoea, 521. 
as alterants, 521. 

tartar emetic, 521. 

mode of administration, 521. 

objections to, 522. 

cathartics, 522. 

mercurial cathartics, 524. 

saline cathanics. 524. 
mercurials as alterants, 524. 
sudorifics, 525. 
acerare of potash, 526. 
sulphate of quinia, 526. 
organic vegetable acids, 527. 

malic, tartaric, acetic, citric, 527. 
treatment of more advanced and final 

stages 534. 
stimulating diaphoretics, 536. 

carbonate of ammonia, 536. 

infusion of serpent aria, 536. 

eupatorium, 536. 
cautions with regard to cold to the 

head. 537. 
high warmth of brain necessary to 

its action, 538. 
mineral acids, 538. 
astringents, 539. 

mineral, 540. 

metallic, 540. 
vegetable tonics, 541. 
glandular and cellular suppurations, 

551. 
stimulating treatment, 551. 
emollient poultices, 551. 
perforation of bowel, 551. 

diagnosis of, 551. 

treatment, 552. 
retention of urine, 552. 
application of ice above the sym- 

pbysis, 552. 
catheierism. 552. 
disorganizing substances, 553. 
disinfecting substances, 553. 
chloride of lime, 553. 
nitrate of lead, 553. 
chloride of zinc, 553. 
Burnett's fluid, 553. 
experiments with, 553. 



U. 



Urticaria, 614. 



Urticaria, prevalence, 614. 

diagnosis, 614. 

remote causes, 615. 

pathological causes, 615. 

prophylaxis, 616. 

treatment, 616. 

cases, 616-17. 

chronic cases, 618. 
Utero-hemorrhagic diathesis, 950. 



V. 



Vaccination, 572. 

history of, 572. 

value as a prophylactic, 572. 

popular objections to, 573. 

proposed legislative enactments con- 
cerning, 573. 

mortality in cases thus protected, 574. 

objections to inoculation, 574. 

subjects, 575. 

management, 575. 

after inoculation, 583. 

during continued exposure to vario- 
lous infection, 584. 
Vaccine infection from the cow, 581. 

matter, 575. 

operation, 575. 

diagnosis, 576. 

Bryce's test, 576. 
Vaccinia, 564. 
Varicella, 584. 
Varieties of scarlatina, 596. 
Variola, 564. 
Varioloid, 564. 
Vegetable bitters*, 64. 
Vegetation, living, 24. 
Vegeto-animalcular hypothesis of autumnal 

fever. 37. 
Venesection, 116. 

Vesico-pustular eruptive fevers, 564. 
Vicksburg, yellow fever at, 281. 



W. 

Warmth of brain necessary to its action 

538. 
Washington, 270. 
Waterloo, yellow fever at, 252. 
Woodville, 257. 
Wounds, 667. 



Y. 



Yellow fever, 187. 

nomenclature, 187. 
definition, 187. 
sources of information, 187. 
geography of, 188. 
chronology of, 189-90. 
local history, 191. 
in New Orleans, 192. 
condition of the city, 192. 

climate, 193. 

commerce, 194. 

population, 195. 
commencement and mortality of the 

fever in different years, 196. 
table of comparison with autumnal 
fever, 197. 



984 



INDEX. 



Yellow fever, conclusions deduced from 
that table, 198. 
relative prevalence of yellow fever 
and autumnal fever in different 
months, 199. 
annals of, at New Orleans, 201. 
seasons of 1791, 201. 
1796, 202. 

1799, 203. 

1800, 203. 

1801, 203. 
1804, 204. 

1807 to 1816, 203-4. 

1817, 204. 

1818, 205. 

1819, 205. 

1820, 205. 

1822, 205. 

1823, 206. 

1824, 206. 

1826, 207. 

1827, 207. 

1828, 207. 

1829, 207. 

1830, 207. 

1831, 207. 

1832, 207. 

1833, 208. 

1834, 208. 

1835, 208. 

1836, 208. 

1837, 208. 

1838, 209. 

1839, 209. 

1840, 209. 

1841, 209. 

1842, 209. 

1843, 210. 

1844, 210. 

1845, 210. 
1846,210. 

1847, 210. 

1848, 211. 

in places E. and S. E. of delta of 
Mississippi, 211. 
• in Balize, 211. 
no cases at Forts St. Philip, Jackson, 

Wood, Pike, 213. 
in civil stations between New Or- 
leans and Mobile, 213. 
at Bay of St. Louis, 213. 
season of 1820, 213. 

1829, 214. 

1839, 215. 
Bay of Biloxi, 215. 
Pascagoula Bay, 215. 
observations on, by a Gulf commander, 

215. 
Bay and City of Mobile, 216. 
season of, 1705, 216. 

1765, 216. 

1765-1819, 216. 

1819, 217. 

1820-24, 219. 

1825, 219. 

1826-8,219. 

1829, 220. 

1830-36, 220. 

1837, 220. 

1838-9, 221. 

1840-42, 222. 

1843, 223. 



Yellow fever, seasons of 1844-6, 224. 
1847-49, 225. 
at Blakeley, 225. 
Pensacola Bay, 225. 
season of 1765, 226. 
1811-1822,227. 
1823-27, 230. 
1828-33, 231. 
1834, 232. 
1835-39, 233. 
1841, 234. 
1842-5, 235. 
1843, 235. 
limited to ships on Gulf, 231. 
the Natchez, 231. 
the Hornet, 231. 
the Vincennes, 232. 
lower town of Bayou Sara, 255. 
upper town St. Francisville, 266. 
Woodville, 257. 
season of 1844, 257. 
town of Fort Adams, 262. 
season of 1839, 262. 
Natchez, 262. 
season of 1825-9, 273. 
1837-9, 275. 
1840-45, 276. 
seasons before 1817, 262. 
season of 1817, 263. 
1819,264. 
1820-22, 265. 
1823, 266. 
1824-5, 269. 
Washington, 270. 
Rodney, 277. 
season of 1843,277. 
Vicksburg, 281. 
season of 1841, 281. 

1844-5, 282. 
Memphis, 283. 
season of 1828, 283. 
Gallipolis, 285. 
New Design, 285. 
Fort Smith, 286. 

etiological deductions from foregoing 
■ facts, 287. 

facts against contagion, 288. 
does not conform to the laws of con- 
tagious fevers, 289. 
predisposing impress of impure air is 
a necessary condition to the action 
of contagion of, 290. 
objections to this view, 290. 
hypotheses of contagious fermenta- 
tion, 291. 
St. Joseph's, 235. 
Apalachicola Bay, 235. 
Tampa Bay, 235. 
Key West or Thompson's Island, 

235. 
season of 1824, 235. 
at places W. and N. W. of New Or- 
leans, 236. 
Galveston, 236. 

topography, 236. 
climate, 237. 
age and population, 237. 
season of 1839, 238. 
Franklin, 238. 

season of 1839, 238. 
New Iberia, 241. 
season of'1839, 241. 



INDEX. 



985 



Yellow fever, at St. Martinville, 24?. 
Opelousas, 242. . 

season of 1837, 242. 

1839, 243. 

1842, 244. 
Alexandria, 245. 

1839, 245. 
Natchitoches, 245. 
Thibodeauxville, 246. 

season of 1839, 246. 
at places up Mississippi, 246. 
Donaldsonville, 246. 

1839, 246. 

1840-3, 247. 
. Plaquemines, 248. 

seasons of 1829-1845, 209. 
Baton Rouge, 250. 

1817-1829,250. 

1843-5, 251. 
Port Hudson, 251. 

season of 1839, 251. 

1841-3, 251, 252. 
Waterloo, 252. 

1839, 252. 
Bayou Sara and St. Francisville,253. 

1811-1829, 253. 

1839, 254. 
symptoms, 298. 
stages, 298. 
stage of depression, 299. 

reaction, 300. 

exhaustion, 301. 
modifying influences, 303. 
pathological anatomy, 303. 
special lesions, 304. 
stomach, 304. 
duodenum, 305. 
other intestines, 306. 
liver, 306. 
gall-bladder, 307. 
bile, 307. 
spleen, 308. 
pancreas, 309. 
mesenteric ganglia, 309. 
kidney, 309. 
bladder, 309. 
urine, 310. 
peritoneum, 310. 



Yellow fever, lungs, 310. 

pleura, 310. 

heart, 310. 

brain, 311. 

spinal cord, 311. 

ganglions and plexuses of great sym- 
pathetic, 312. 

muscles of animal life, 313. 

skin, 313. 

generalizations, 314. 

lesions of blood, 316. 

hemorrhages, 317. 

black vomit, 317. 

pathology, 319. 

treatment, 321. 

self-limitation, 321. 

prevention, 321. 

remedies for 1st and 2d stages, 322. 

diversities of treatment, 322. 

bloodletting, 322. 

local bleeding, 328. 

cathartics, 331. 

rules for use of, 334,. 

calomel, 335. 

objections to calomel, 335. 

non-purgative alkaline salts, 336. 

formula for, 337. 

muriate of ammonia in third stage 
337. 

sulphate of quinine, 337. 
of cornine, 338. 

applications to the skin, 342. 

irritants, 342. 

sudorifics, 343. 

remedies in third stage, 343. 

general directions, 344. 

positive treatment, 345. 

stimulation, 345. 

surviving inflammations, 346. 

impoverished and deteriorated state 
of blood, 347. 

suspended state of secretions, 348. 

diarrhoea, bilious, 349. 

black vomit, 349. 

miscellaneous observations, 351. 

mortality, 351. 

compared with autumnal fever, 353. 

tabular view of comparison, 354. 



63 



THE UNITED STATES DISSECTOR; 

OR, 

UESSONS IN PRACTICAL AMTOMY. 

BY WM. E. HORNER, M. D. 

Fifth edition, 1 vol. 12mo. 

CAREFULLY REVISED, AND ENTIRELY REMODELLED, 

BY HENRY H. SMITH, M. D. 

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TRANSLATED FROM THE FRENCH, 

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pace with the progress of Operative Surgery on this continent." — Boston Med. and Surg. Journal, 
Nov. 1852. 



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